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WAR   NEUROSES 


By 

JOHN  T.  MacCURDY, 

Lieut.,  Medical  Officers'   Reserve   Corps,  U.  S.  A. 


Reprinted  from   "  PSYCHIATRIC   BULLETIN  "    for  July,  1917 


UTICA,  N.  Y. 

STATE  HOSPITALS  PRESS 

1918 


WAR  NEUROSES. 
By  Dr.  John  T.  MacCurdy, 

Psychiatric  Institute  of  the  New  York  State  Hospitals. 

War  neuroses  may  be  defined  as  those  functional  nervous 
conditions  arising  in  soldiers,  which  are  immediately  deter- 
mined by  the  conditions  of  modern  warfare^  and  have  a 
symptomatology  whose  content  is  directly  related  to  war. 
Naturally  enough,  in  any  large  body  of  troops,  neuroses  (as 
well  as  psychoses)  develop  as  they  do  in  times  of  peace,  and 
many  of  these  are  determined  by  factors  which  are  essen- 
tially those  of  civilian  life.  In  these  latter  the  symptoms 
are  the  same  as  those  occurring  in  peace  times,  and  can 
therefore  not  be  called  war  neuroses  with  any  clinical  accu- 
racy. This  group  of  functional  nervous  diseases  presents 
no  problems  that  are  different  from  those  which  have  been 
studied  for  many  years,  and  they  shall  therefore  receive  no 
attention  in  the  preliminary  clinical  report  which  follows. 

The  war  neuroses,  however,  offer  problems  very  new  and 
of  great  importance  both  from  medical  and  military  stand- 
points. The  term  ' '  shell  shock  ' '  has  been  adopted  ofl&cially 
by  the  British  War  Office  as  the  diagnostic  term  to  cover  all 
neuroses  arising  among  officers  and  soldiers  of  the  armies. 
This  term  has  an  advantage  in  its  picturesqueness  that  has 
helped  to  stimulate  popular  as  well  as  professional  interest, 
but  it  is  a  term  which  can  be  defended  with  difficulty  from 
a  purely  medical  standpoint.  There  are  two  reasons  why 
this  is  so.  In  the  first  place  it  implies  a  single  etiology — the 
physical  effects  of  high  explosive  shells  on  those  subjected 
to  bombardment,  who  suffer  no  external  physical  injury — 
and  this  is  far  from  being  even  the  main  factor  in  the  deter- 
mination of  the  symptoms.  Secondly,  the  clinical  types 
covered  by  this  blanket  diagnostic  term  are  too  various  to 
be  safely  gathered  under  one  heading.  It  is  therefore  more 
advisable  to  use  the  term  "war  neuroses,"  which  gives  the 
desired  latitude  in  grouping  together  the  different  clinical 
pictures  that  occur,  and  focuses  the  attention  on  those 
influences  which  come  directly  from  warfare. 


In  most  countries,  at  the  outbreak  of  the  present  war,  a 
situation  was  in  existence  that  was  distinctly  inimical  to  the 
careful  study  of  functional  nervous  diseases.  Neurotics, 
with  their  tendency  to  superficial  recovery  and  frequent 
relapses,  were  insoluble  problems  to  the  bulk  of  the  profes- 
sion who  were  not  especially  trained  in  their  treatment,  so 
that  they  had  become  the  betes  noires  of  most  general  prac- 
titioners and  of  man}^  neurologists.  Being  little  understood, 
the  general  ignorance  as  to  causation  led  to  the  adoption  of 
hypotheses  concerning  the  essential  nature  of  these  con- 
ditions, which  were  more  strongly  held  than  scientific 
accuracy  would  justify.  This  was,  of  course,  a  natural 
consequence  of  the  multiplicity  of  phj'sical  and  psycholog- 
ical factors  that  are  probably  always  at  work  in  the 
production  of  peace  neuroses. 

Neurotics,  too,  demand  so  much  time  of  the  physician  in 
treatment  that  a  tendency  had  developed  to  regard  their 
symptoms  as  purely  imaginary,  somewhat  spurious,  or  at 
least  of  less  importance  than  obviously  organic  medical 
problems.  The  average  medical  practitioner  naturally  pre- 
ferred to  give  his  attention  to  concrete  physical  disabilities 
rather  than  to  impalpable  and  subjective  symptoms.  When 
the  war  appeared,  therefore,  the  medical  attitude  toward 
neuroses  was  one  of  rather  narrow  bigotry  on  the  part  of 
most  of  that  small  group  interested  in  functional  nervous 
diseases,  and  of  indifference  on  the  part  of  the  bulk  of  the 
profession.  Naturally  then,  there  were  few  observers  who 
were  really  competent  to  study  the  great  mass  of  material 
which  the  war  suddenly  produced. 

These  thousands  of  cases  presented  problems  which  were 
no  less  important  from  a  military  than  from  a  medical  stand- 
point, and  hypotheses  as  to  their  essential  nature  were  put 
forth  with  as  much  enthusiasm  and  as  little  accuracy  as  the 
importance  of  the  problem,  on  the  one  hand,  and  the  lack 
of  preparation  on  the  part  of  the  observers,  on  the  other, 
would  naturally  be  expected  to  produce.  Those  who  had 
had  little  sympathy  with  the  neurotic  looked  on  these  vic- 
tims of  war  as  mere  malingerers  and  advised  treatment  by 
a  firing  squad — "  pour  encourager  les  autres." 


Those  wTio  had  been  previously  interested  in  hereditary 
defects  asserted  that  these  new  patients  were  practically  all 
inferior  individuals.  Those  who  had  emphasized  physical 
factors  in  peace  times  were  able  to  demonstrate  to  their  sat- 
isfaction that  all  the  cases  were  suffering  from  extreme 
physical  fatigue,  concussion  from  high  explosive  shells,  or 
poisoning  with  gases  from  the  explosives.  On  the  other 
hand,  there  were  those,  who  had  worked  with  neurotics  from 
a  psychological  standpoint,  who  took  the  ground  that  the 
war  neuroses  were  essentially  psychic  in  origin.  As  a  re- 
sult of  this,  a  large  literature  has  grown  up  which  must  be 
rather  chaotic  for  the  average  American  to  whom  it  is  acces- 
sible, since  few  publications  are  to  be  found  which  give  any 
broad  survey  of  the  clinical  material,  or  a  careful  study  of 
all  possible  factors.  It  therefore  seemed  advisable  to  make 
a  survey  of  these  cases,  bearing  constantly  in  mind  the 
possibility  of  all  the  above  mentioned  factors  coming  into 
play,  in  order  that  their  relative  importance  might  be  gauged 
as  a  basis  for  the  further  study  and  treatment  of  these  con- 
ditions as  they  arise  in  the  American  expeditionary  forces. 

The  cases  now  to  be  reported  were  observed  in  seven  hos- 
pitals in  England:  five  of  them  in  London,  one  in  the 
neighborhood  of  Liverpool  and  one  near  Edinborough. 
They  embrace  neuroses  occurring  both  in  officers  and  men, 
and  arising  in  the  extremely  varied  circumstances  of  mod- 
ern warfare.  Most  of  the  cases  had  been  out  of  the  firing 
line  for  some  weeks  or  months,  but  a  few  had  been  disabled 
from  active  service  for  only  a  few  days.  Unfortunately  it 
was  not  possible  in  the  two  months  at  my  disposal  to  visit  the 
front  and  examine  similar  material  in  its  more  acute  stages. 
As  a  result,  it  is  impossible  to  describe  on  the  basis  of  per- 
sonal observation  the  "stuporous"  states  that  are  said  to 
exist  for  a  short  time  in  many  of  the  cases.  For  the  pur- 
poses of  this  preliminary  account,  no  neuroses  developing 
during  the  period  of  training  have  been  included.  What 
material  is  presented,  as  a  foundation  for  statements  as  to 
etiology,  was  gathered  by  taking  careful  histories  from  the 
patients  themselves,  and  discussing  the  problems  freely  with 
those  who  had  spent  months  or  years  in  the  observation  and 


treatment  of  these  diseases.  This  work  was  not  only  greatly 
facilitated,  but  was  made  a  pleasurable  task  by  the  extraor- 
dinary cooperation  and  cordiality  which  was  everywhere 
found  in  the  British  hospitals.  It  is  impossible  to  state  too 
strongly  my  appreciation  of  the  opportunities  that  were  given 
me,  and  of  the  kindness  with  which,  as  an  American,  I  was 
received. 

In  order  to  orient  the  reader  at  the  outset  with  the  nature 
of  these  neuroses,  it  may  be  well  to  note  cases  representa- 
tive of  the  two  main  types  which  are  to  be  found.  These 
are  conditions  of  anxiety  on  the  one  hand,  and  of  simple 
conversion  hysteria  on  the  other. 

Case  I.  The  following  history  is  typical  of  the  development  and 
symptoms  of  an  anxiety  state.  The  patient  was  a  man  of  27  who  had 
never  been  ill  in  his  life.  He  had  never  shown  any  neurotic  tenden- 
cies, having  been  entirely  free  from  night  terrors  as  a  child,  and  had 
suffered  from  none  of  the  fears  or  inhibitions  so  constantly  met  with 
among  neurotics  in  peace  times.  He  had  never  had  any  fear  of  high 
places,  or  thunder-storms,  or  crowds,  or  entering  tunnels,  and  had  had 
no  sensitiveness  to  bloodshed.  He  had  been  a  normal,  mischievous 
boy,  had  played  many  games,  and  had  been  successful  in  his  work, 
both  in  school  and  when  he  entered  business  life.  The  only  abnor- 
mality to  be  found  in  his  make-up  was  a  certain  shyness  with  the  other 
sex,  from  which  he  had  never  entirely  freed  himself.  It  was  perhaps 
for  this  reason  that  he  was  unmarried  and  had  never  thought  of  taking  a 
wife.  It  is  interesting  to  note  that  he  always  despised  those  who  de- 
veloped neuroses  of  any  kind,  and  when  he  went  to  France  had  similar 
disrespect  for  those  suffering  from  "shell  shock." 

He  enlisted  as  a  private  in  October,  1914,  and  adapted  himself  pretty 
well  to  the  training,  making  many  friends  among  his  fellow  soldiers 
and  enjoying  the  work  at  first,  although  he  became  rather  bored  with 
the  routine  before  his  five  months  of  training  were  completed.  In 
February,  1915,  he  went  to  the  firing  line  in  France.  In  his  first 
experience  of  shell  fire  he  broke  out  with  a  cold  sweat  with  fear, 
then  became  rather  slow  and  depressed,  without  any  energy,  and 
felt  rather  sleepy.  This  reaction,  however,  was  only  temporary.  He 
soon  became  accustomed  to  bombardment  and  the  sight  of  wounds  and 
death,  and  then  began  to  enjoy  his  work,  particularly  the  active  oper- 
ations. After  eight  months  in  the  trenches  he  was  invalided  home 
with  nephritis.  He  was  convalescent  for  four  months,  and  was  rec- 
ommended for  a  commission,  which  he  received  after  two  months 
training.  Two  months  more  being  spent  in  his  regimental  depot,  he 
returned  to  France  as  a  lieutenant  in  June,  1916.  Then  followed  four 
months  of  very  heavy  fighting  on  the  Somme,  during  which  time  he 


developed  no  symptoms  whatever.  He  was  wounded  very  slightly 
once.  One  day  he  was  buried  three  times  by  earth  thrown  up  from 
shell  explosions.  The  last  time  he  was  unconscious  for  ten  minutes. 
He  was  relieved  for  three  days  after  this  experience,  although  he  had 
no  symptoms.  He  was  very  frequently  knocked  out  for  short  periods 
by  the  concussion  from  shells.  About  the  end  of  October,  1916,  he 
was  sent  to  the  Ypres  section  where  he  was  working  with  a  pioneer 
battalion  and  had  to  bury  many  dead.  This  has  been,  since  the  outset 
of  the  war,  the  most  trying  part  of  the  whole  British  line.  Not  only 
has  bombardment  been  practically  constant  from  the  beginning,  but 
to  add  to  the  other  horrors  of  the  situation  it  has  never  been  possible 
to  bury  all  the  dead.  In  this  disagreeable  situation  he  began,  after 
a  month  of  these  new  duties,  to  dislike  the  work,  and  became  mildly 
depressed,  although  he  paid  no  particular  attention  to  his  feelings. 
Then  some  fatigue  set  in,  and  he  found  himself  for  the  first  time  since 
his  initial  experience  of  shell  fire  with  a  tendency  to  jump  nervously 
when  the  shells  came.  To  keep  himself  in  hand  he  began  to  drink. 
After  a  couple  of  weeks  he  found  that  his  sleep  was  becoming  poor. 
It  took  him  a  long  time  to  get  to  sleep,  during  which  time  the  scenes 
on  the  Somme  front  were  constantly  in  his  mind.  He  had  a  feeling 
that  he  had  to  get  up  to  the  trenches  on  the  Somme  the  next  day,  and 
that  he  did  not  want  to  go.  During  this  period  of  half-sleeping,  half- 
waking,  he  suffered  from  "hypnagogic"  hallucinations;  that  is,  vis- 
ions of  the  trenches,  shells,  and  so  on,  accompanied  by  insight  that 
they  were  really  not  there,  but  only  imaginations.  These  visions  pro- 
duced no  fear.  At  this  time  he  had  no  nightmares.  Matters  grew 
worse.  Every  week  he  became  more  nervous;  fear  of  the  shells  grew 
on  him,  he  lost  the  ability  to  tell  by  the  sound  where  each  was  going 
to  land,  and  all  of  them  seemed  to  be  coming  at  him.  In  the  effort  to 
"quiet  his  nerves  "  he  got  to  drinking  quite  heavily  by  the  beginning 
of  the  present  year.  He  struggled  constantly  to  prevent  any  outward 
signs  of  his  fear  betraying  his  condition  to  his  men.  This  effort  in- 
creased his  fatigue.  The  horror  that  he  felt  when  first  confronted 
with  the  bloodshed  of  battle,  and  to  which  he  had  long  since  become 
accustomed,  reappeared  at  this  time.  He  became  sensitive  to  all  the 
sights  that  were  forced  on  his  eyes,  would  think  of  them  when  alone 
and  not  actively  engaged  on  some  duty,  and  would  see  them  before 
him  on  falling  off  to  sleep.  He  was  so  discouraged  that  he  began  to 
wish  he  might  be  killed. 

He  was  able  to  continue,  however,  until  March,  when  on  a  raid  one 
day  seven  men  around  him  were  killed  and  he  was  immediately  after- 
ward buried  himself.  After  this  he  felt  so  much  worse  that  he  applied 
to  the  doctor,  who  told  him  he  had  some  fever  and  gave  him  a  "  pick- 
me-up.  ' '  He  ' '  carried  on  ' '  for  two  days,  but  with  extreme  difficulty; 
then  his  condition  became  so  bad  that  he  was  forced  to  report  to  his 
physician  again,  and  was  sent  to  a  hospital.  For  two  or  three  weeks 
he  had  had  bad  headaches  back  of  his  eyes,  his  sleep  had  become  very 
limited  as  he  would  constantly  awake  with  a  jump. 


As  soon  as  he  got  into  the  hospital  he  began  having  nightmares 
which  were  typical  of  the  anxiety  state.  In  them  he  was  back  on  the 
Somme  front  and  being  shelled  mercilessly.  Shells  would  come 
closer  and  closer  to  him,  finally  one  would  land  right  on  top  of  him 
and  he  would  awake  with  a  shriek  of  terror.  After  a  long  time  he 
would  go  to  sleep  again,  to  be  almost  immediately  reawakened  with 
another  of  these  dreams,  the  content  being  always  the  same  and 
confined  to  fighting,  in  which  he  was  invariably  getting  the  worst 
of  it. 

He  would  awaken  in  the  morning  feeling  weak,  absolutely  played 
out.  Any  noise  would  be  interpreted  as  a  shell  and  strike  him  with 
terror.  He  was  therefore  suffering  from  a  combination  of  fatigue  and 
extreme  nervousness,  with  the  war  constantly  in  his  thoughts.  At 
night  when  falling  off  to  sleep  he  would  have  "hypnagogic"  hallu- 
cinations of  Germans  entering  the  room,  and  with  these  visions,  too, 
there  was  great  terror. 

After  being  a  little  over  a  week  in  different  hospitals  in  France,  hd 
was  transferred  to  London.  There  his  condition  greatly  improved,  his 
fatigue  lessened,  he  became  less  sensitive  to  noises  and  his  night- 
mares largely  disappeared.  He  was  then  sent  to  a  hospital  in  the 
country  where  he  had  every  opportunity  for  out-door  exercise  and 
recreation  and  continued  to  improve  for  two  weeks.  Then  came  the 
news  of  the  death  of  one  of  his  best  friends  in  France,  which  de- 
pressed him  considerably.  Shortly  after  this  a  concert  was  arranged 
at  the  hospital  and  he  tried  to  sing,  but  failed.  This  experience  made 
him  much  worse.  The  old  dreams  began  to  destroy  his  sleep  with 
great  regularity.  He  became  more  disheartened  and  hypochondriacal, 
complained  that  he  was  in  a  sweat  day  and  night,  that  he  had  lost 
twelve  pounds  and  that  he  was  never  going  to  get  well  because  his 
physicians  would  not  give  him  an  opiate.  (As  a  matter  of  fact,  at 
this  time  his  sleep  was  fairly  good.)  He  could  not  be  induced  to 
leave  the  hospital  and  would  not  go  out  of  doors  for  a  week  at  a  time. 
He  felt  so  much  weaker  that  he  was  no  longer  able  to  play  golf.  He 
was  in  general  quite  convinced  that  he  was  physically  and  nervously 
a  permanent  wreck. 

This  case  is  typical,  except  for  the  occurrence  of  the 
relapse  with  depression. 

Case  II.  This  case  illustrates  a  simple  hysterical  conversion.  The 
patient  is  a  private  of  20  years  of  age,  who  is  not  quite  so  normal 
as  the  individual  whose  history  has  just  been  cited.  Although  he 
had  never  had  any  neurotic  symptoms,  he  showed  a  tendency  to 
abnormality  in  his  make-up.  He  was  rather  tender-hearted  and 
never  liked  to  see  animals  killed.  Socially,  he  was  rather  self- 
conscious,  inclined  to  keep  to  himself,  and  had  not  been  a  perfectly 
normal,  mischievous  boy,   but  was   rather  more  virtuous  than  his 


companions.  He  had  always  been  shy  with  girls  and  had  never 
thought  of  getting  married.  All  of  these  seclusive  tendencies, 
however,  were  quite  mild  in  degree.  The  one  physical  trouble  from 
which  he  ever  suffered  was  a  sore  throat  a  year  or  so  before  the  war 
began.  At  this  time  he  was  unable  to  sing  or  to  talk  loudly  without 
hurting  his  throat.     He  had  always  had  a  lisp. 

He  enlisted  in  May,  1916,  and  spent  five  months  in  training.  This 
proved  to  be  distinctly  advantageous,  for  he  adapted  himself  well  to 
it  and  was  mentally  more  comfortable  than  before,  as  was  shown  by 
his  increasing  sociability.  On  going  to  the  front,  October,  1916,  he 
found  himself  frightened,  as  is  usual,  by  the  first  shell  fire  he  encoun- 
tered, and  horror-struck  by  the  sight  of  wounds  and  death,  but  soon 
became  free  from  fear  and  quite  accustomed  to  the  horrors  around  him. 
After  five  months  of  fighting,  he  was  sent  to  Armentieres  in  March, 
1917,  and  had  to  fight  for  three  days  without  sleep.  He  became  tired, 
developed  no  anxiety  or  "  jumpiriess, "  but  felt  a  strong  desire  to  get 
out  of  the  fatiguing  situation  in  which  he  found  himself.  This  desire 
did  not  show  itself,  as  in  the  previous  case,  in  a  wish  to  be  killed,  but 
rather  in  the  hope  that  he  might  receive  wounds  which  would  inca- 
pacitate him  from  service,  for  a  time  at  least. 

Then  he  was  suddenly  buried  by  a  shell.  He  did  not  lose  conscious- 
ness, but  when  dug  out  by  his  companions  he  was  found  to  be  deaf 
and  dumb.  On  his  way  to  the  field  dressing  station  he  had  a  fear  of 
the  shells,  but  this  did  not  persist  after  his  leaving  the  zone  that  was 
under  bombardment- 
Physical  examination  revealed  absolutely  no  abnormality,  of  course, 
to  account  for  his  deafness  and  inability  to  speak.  It  was  a  purely 
hysterical  condition,  and  persisted  unchanged  for  a  month.  He  was 
then  transferred  to  a  hospital  for  the  treatment  of  functional  cases, 
where  he  was  completely  and  permanently  cured  in  less  than  five 
minutes.  This  cure  was  effected  by  demonstrating  to  the  patient  that 
he  had  not  really  lost  his  hearing,  the  method  employed  being  to 
make  him  face  a  mirror  and  observe  the  start  he  gave  when  hands 
were  clapped  behind  him.  He  was  spoken  to  immediately,  and  told 
that  the  jump  he  had  just  given,  which  he  had  himself  observed  in 
the  mirror,  was  evidence  that  he  had  heard  the  hand  clapping,  and 
that,  as  his  hearing  was  not  lost,  neither  was  his  speech.  He 
promptly  replied  verbally,  and  had  no  relapses  during  the  two  months 
before  I  saw  him.  All  this  time  he  did  not  suffer  from  nightmares 
or  from  any  other  anxiety  symptoms. 

This  case  is  typical  of  the  simple  conversion  hysteria 
that  develops  under  the  stress  of  warfare.  Not  only  the 
history  and  symptoms  are  typical,  but  the  speedy  and 
apparently  permanent  recovery  under  competent  treatment 
is  equally  representative  of  this  group. 


8 

With  these  two  cases  in  mind  we  may  proceed  to  a  few 
general  considerations.  Officers  are  affected  in  the  propor- 
tion of  five  to  one  as  compared  with  privates  and  non-com- 
missioned officers,  although  in  absolute  numbers  there  are 
more  in  the  latter  group,  of  course.  Explanations  for  this 
discrepancy  will  be  offered  later.  As  to  the  total  number 
of  neuroses  developing  in  the  different  armies,  there  are  no 
statistics  available  for  general  publication.  But  I  have  been 
informed  that  "shell  shock"  ranks  with  what  were  pre- 
viously considered  the  more  important  conditions  (excluding 
wounds)  operating  to  remove  men  temporarily  or  permanently 
from  active  service.  This  makes  it  at  once  evident  that 
functional  nervous  troubles  are  an  extremely  important 
medical  problem.  Unlike  other  causalities,  however,  there 
is  a  military  significance  in  the  nature  of  these  neuroses. 
These  do  not  merely  cause  the  removal  of  many  men  from 
active  service.  As  can  be  easily  seen  in  the  first  case 
quoted,  there  may  be  the  development  of  a  state  of  fear 
which  may  last  for  weeks  or  months  before  the  symptoms 
accumulate  sufficiently  to  incapacitate  the  soldier  totally. 
No  matter  how  much  any  man  may  try  to  hide  his  fear,  he 
can  not  but  unconsciously  betray  it,  and  so  weaken,  or  tend 
to  weaken,  the  morale  of  his  group.  This  is  not  merely  a 
psychological  deduction,  but  has  been  confirmed  by  the 
statements  of  many  officers  who  have  observed  these  cases, 
and  whom  I  had  the  opportunity  of  questioning  on  the 
subject. 

Another  point  of  military  importance  is  that  war  neuroses 
are  apparently  a  corollary  of  modern  methods  of  fighting. 
The  first  reports  of  these  conditions  came  from  the  Russo- 
Japanese  war,  which  would  indicate  that  there  is  something 
in  the  modern  trench  warfare,  combined  with  the  appalling 
artillery  fire,  which  tends  to  produce  a  condition  of  what 
might  loosely  be  termed  neuro-psychic  instability.  I  have 
had  the  opportunity  of  asking  several  officers  who  served 
both  in  South  Africa  and  in  the  present  war  about  this 
matter.  The  answers  are  quite  consistent.  Practically  all 
the  officers  now  in  France  are  familiar  with  the  clinical 
pictures  of  the  war  neuroses,  and  are  therefore  competent 


to  say  whether  they  existed  in  the  Boer  war  or  not.  None 
of  them  observed  anything  at  all  similar.  It  is  impossible 
to  consider  that  the  human  race  can  have  deteriorated 
appreciably  in  a  matter  of  fifteen  years,  and  therefore  we 
are  safe  in  assuming  that  it  is  modern  warfare  which  has 
produced  these  conditions. 

Medical  interest  in  these  cases  should  naturally  exceed 
the  interest  of  the  professional  soldier.  It  is  the  responsi- 
bility of  the  medical  corps  to  treat  the  sick  and  prevent 
diseases  from  developing.  The  responsibility  of  the  army 
medical  ofi&cer  must  now,  however,  go  further  than  this,  for 
the  all  important  discrimination  between  a  definite  disease 
and  malingering  can  be  made  only  by  him. 

To  those  who  are  interested  in  psychological  medicine 
there  is  here  a  new  field,  and  a  highly  important  one, 
opened  up.  We  find  in  these  cases  a  great  simplicity  in 
the  psychic  mechanisms  operating  to  produce  symptoms  and 
the  appearance  of  severe  neuroses  in  people  who  were 
apparently  absolutely  normal  before  their  exposure  to  the 
horrors  and  hardships  of  this  war.  We  find  wishes,  fully 
conscious  to  the  subject,  directly  determining  symptoms, 
simple  therapeutic  measures  leading  to  permanent  recovery 
with  astonishing  rapidity,  and,  on  the  other  hand,  we  see  a 
chronicity  of  symptoms  for  which  no  treatment,  or  improper 
treatment,  is  given. 

In  all  these  respects  we  discover  an  extraordinary  con- 
trast to  the  phenomena  exhibited  by  neurotics  in  times  of 
peace.  It  is  therefore  reasonable  to  hope  that  psycho- 
pathology  can  profit  greatly  by  a  careful  study  of  the  war 
neuroses.  Without  minimizing  the  importance  of  physical 
factors,  it  is  safe  to  say  that  psychic  mechanisms  always 
determine  the  exact  nature  of  the  symptoms.  Physical 
disabilities,  of  course,  frequently  underlie  the  faulty  psychic 
processes.  We  must  therefore  consider  at  the  outset  how 
our  previous  psychopathological  knowledge  can  be  applied 
to  this  novel  material.  In  order  to  gain  our  first  approach 
to  the  problem,  account  must  be  taken  of  what  is  really,  if 
dispassionately  viewed,  an  extraordinary  phenomenon. 

At  the  present  time  there  are  millions  of  men,  previously 


10 

sober,  humdrum  citizens,  with  no  observable  traits  of  reck- 
lessness or  bloodthirstiness  in  their  nature,  and  with  a  nor- 
mal interest  in  their  own  comfort  and  security,  not  only 
exposing  themselves  to  extraordinary  hazards,  but  cheer- 
fully putting  up  with  extreme  discomforts,  and  engaged  in 
inflicting  injuries  on  fellow  human  beings,  without  the  re- 
pugnance they  would  have  shown  in  performing  similar 
operations  on  the  bodies  of  dogs  and  cats.  It  would  be  im- 
possible to  discuss  in  any  completeness  the  mental  mechan- 
isms which  result  in  this  astonishing  change  in  character. 
It  is,  however,  extremely  important  to  develop  some  hypoth- 
esis, no  matter  how  briefly,  to  account  for  this,  because 
one  of  the  phenomena  exhibited  by  the  war  neuroses  is  the 
tendency  to  return  to  the  mental  attitudes  of  civilian  life 
and  to  become  increasingly  obsessed  with  the  horror  of 
warfare. 

Deep  down  in  all  of  us  there  is,  apparently,  a  primitive 
instinct  that  takes  a  delight  in  brutality  and  savagery  for 
themselves  alone.  Among  civilized  peoples  these  tenden- 
cies are,  in  normal  circumstances,  quite  thoroughly  re- 
pressed, and  gain  an  outlet,  as  William  James  has  suggested, 
only  in  physical  exertions,  dangerous  exploits  and  rough 
and  tumble  athletic  contests.  The  origin  of  this  repres- 
sion is  probably  to  be  found  in  the  instinct  of  gregari- 
ousness  in  the  human  species,  which  increases  in  its  power 
with  the  advance  of  civilization,  and  is  necessarily  in  con- 
flict with  all  individualistic  instincts,  whose  operation 
would  be  inimical  to  the  interests  of  society.  The  repug- 
nance, therefore,  of  the  modern  civilized  man  to  cruelty  and 
bloodshed  is  probably  based  on  the  fact  that,  during  cen- 
turies of  development,  the  race  has  frowned  upon  all  lawless 
individual  exhibitions  of  such  tendencies,  and  that  this 
feeling  has  become  part  and  parcel  of  the  individual's 
make-up. 

The  doctrine  of  sublimation,  as  developed  by  the  psycho- 
analytic school  of  psychology,  furnishes  probably  the  only 
effective  explanation  for  the  lifting  of  this  repression  in 
times  of  war.  A  sublimation  is  an  outlet  to  primitive  indi- 
vidualistic  instinct,    rarely   in   a   direct,  more  often  in  a 


11 

symbolic  form,  but  always  so  constituted  as  not  to  be  re- 
pugnant to  society  or  to  the  social  instincts  of  the  subject. 
Any  man  is  not  only  a  member  of  the  human  genus,  but 
also,  and  more  immediately,  a  member  of  a  smaller  group, 
that  is,  a  tribe  or  a  nation.  And  it  is  an  interesting  fact 
that  this  group  is  apt  to  be  more  powerful  in  its  influence 
on  the  man  than  is  the  interest  of  mankind  as  a  whole. 
The  more  primitive  is  any  people,  the  more  does  it  tend  to 
regard  members  of  other  tribes  or  nations  as  belonging  to  a 
different  species,  and  therefore  to  be  treated  as  natural 
enemies,  to  whom  no  sympathy  or  consideration  is  due.  It 
follows  from  this  that  any  man's  instinctive  morality  is 
much  more  strongly  determined  by  the  general  standards  of 
the  group  with  which  he  lives  than  by  any  interest  in  that 
vaguer  conception  of  mankind  as  a  whole.  The  average 
human  being  is  therefore  restrained  in  large  measure  from 
the  development  of  his  tendencies  to  lust  and  cruelty  by  the 
innate  feeling  he  enjoys  of  the  deleterious  effect  such  actions 
would  have  on  his  immediate  fellows.  When  war  develops, 
however,  a  premium  is  put  upon  bloodthirstiness,  and  the 
community  extols  the  individual  who  is  most  effective  in 
inflicting  injuries  upon  the  bodies  and  lives  of  the  members 
of  an  opposing  group. 

This  becomes,  in  effect,  a  sublimation,  for  now  the  soldier 
can,  by  the  same  acts,  give  vent  to  his  primitive  passions 
and  reap  the  approbation  of  his  fellows.  Only  two  factors 
may,  occasionally,  stand  in  the  way  of  a  complete  develop- 
ment of  this  sublimation;  the  fijrst  is  the  habit  of  the  man's 
mind,  who  for  years  has  been  educated  with  ideals  of 
gentleness;  the  second  is  that  degree  of  emotional  unity, 
he  may  possess,  that  binds  him  to  all  mankind,  making 
him  sensitive  to  the  sufferings  of  those  outside  his  group. 
The  combined  influence  of  both  these  factors  is,  apparently, 
insufficient  to  inhibit  an  almost  universal  and  fairly  free 
outlet  to  cruelty  in  the  average  modern  man,  as  the  present 
war  shows.  The  soldier  is  therefore  usually  able  to  take 
delight  in  the  injury  he  inflicts  upon  his  foe,  and  to  become 
callously  immune  to  the  horrible  sights  to  which  he  is 
constantly  exposed,  since  bloodshed,  as  such,  has  ceased 
to  be  colored  with  horror  for  him. 


12 

Another  feature  in  the  psychology  of  war  is  of  clinical 
importance.  Individualistic  and  social,  or  herd  instincts 
are  by  their  very  nature  in  conflict.  The  predominance  of 
one  over  the  other  at  any  given  time  depends  upon  a  num- 
ber of  factors,  one  of  the  most  important  of  which  is  the 
nature  of  the  immediate  stimulus.  In  time  of  war,  either 
the  existence  of  the  tribe  or  nation  is  threatened,  or  there  is 
a  possibility  of  the  power  of  the  group  being  greatly  aug- 
mented. Either  of  these  possibilities  tends  to  stimulate  the 
social  instinct  of  the  individual,  rather  than  his  individual- 
istic cravings.  Consequently  the  citizen  becomes  less  of  an 
individual  and  more  an  integral  part  of  the  society  to  which 
he  owes  allegiance.  He  thinks  less  of  himself.  Greater 
personal  sacrifices  become  possible,  and  he  is  able  to  feel 
his  reward  in  the  advantages  which  accrue  to  his  party  in 
the  struggle.  This  gives  him  the  ability  to  endure  fatigue 
and  deprivation,  even  cheerfully  to  face  death  itself,  in  a 
way  that  would  be  quite  impossible  in  times  of  peace. 
This  and  the  enjoyment  of  bloodshed  probably  constitute 
the  two  most  important  factors  in  the  production  of  the 
change  of  character  which  the  civilian  undergoes  in  be- 
coming a  soldier. 

In  recent  years,  those  who  have  been  interested  in  the 
more  minute  psychological  study  of  neuroses,  particularly 
those  of  the  psycho-analytic  school,  have  found  that  before 
the  onset  of  actual  symptoms,  there  is  apt  to  be  a  period 
during  which  there  are  changes  in  the  patient's  activities 
or  outlook  upon  life.  Very  often  these  changes  are  the 
result  of  environmental  accident,  but,  whether  coming 
from  within  or  without,  they  consist  essentially  in  a  change 
of  his  adaptation  to  the  situation  in  which  he  is  placed, 
and  involve  a  loss  or  weakness  of  sublimations  which  he 
has  previously  enjoyed.  A  knowledge  of  this  phenomenon 
is  of  considerable  aid  in  studying  war  neuroses,  because 
we  find  that  an  analogous  change  takes  place  in  the  adap- 
tation of  the  soldier  to  his  task  before  the  appearance  of 
active  symptoms.  Anyone,  who  is  at  all  familiar  with 
the  phenomena  of  modern  trench  warfare,  can  see  that  it 
makes  a  great  demand  on  the  devotion  of  the  belligerents 


13 

and  offers  little  personal  satisfaction  in  return.  In  pre- 
vious wars  the  soldiers,  it  is  true,  were  called  upon  to  suffer 
fatigue  and  expose  themselves  to  great  danger.  In  return, 
however,  they  were  compensated  by  the  excitement  of  more 
active  operations,  the  more  frequent  possibility  of  gaining 
some  satisfaction  in  active  hand  to  hand  fighting,  where 
they  might  feel  the  joy  of  personal  prowess.  Now,  the  sol- 
dier must  remain  for  days,  weeks,  even  months,  in  a  narrow 
trench  or  a  stuffy  dugout,  exposed  to  a  constant  danger  of 
the  most  fearful  kind;  namely,  bombardment  with  high 
explosive  shells,  which  come  from  some  unseen  source,  and 
against  which  no  personal  agility  or  wit  is  of  any  avail. 
This  naturally  occasions  great  fatigue,  and,  on  the  other 
hand,  opportunities  of  active  hand  to  hand  fighting  are 
rare,  so  that  a  man  may  be  exposed  for  months  to  the 
appalling  effects  of  bombardment  and  never  once  have  a 
chance  to  retaliate  in  a  personal  way.  Consequently  the 
sublimations  described  above  are  more  difficult  to  maintain 
than  in  any  previous  war.  The  soldier  becomes  fatigued 
(developing  symptoms  which  will  be  discussed  later)  and 
not  unnaturally  finds  it  difficult  to  remain  satisfied  with  his 
situation.  His  adaptation  to  warfare  is,  therefore,  soon 
weakened  or  lost.  His  disregard  of  the  carnage  and  death 
around  him  is  gone,  and  he  becomes  every  daj'^  more 
acutely  sensitive  to  the  horrors  which  surround  him.  This 
sensitiveness  may  develop  even  to  the  point  of  pity  for  the 
foe,  which  is  naturally  an  emotion  most  incapacitating  for 
a  soldier. 

With  this  dislike  for  the  war  there  is  inevitably  some 
degree  of  resentment  at  the  State  which  has  sent  him  to 
fight,  although  this  is  apt  to  come  only  vaguely  into  full 
consciousness.  The  bonds  uniting  him  to  the  common 
cause  are  definitely  loosened,  however,  and  as  a  consequence 
his  individual  feelings  begin  to  assert  themselves.  Acci- 
dents to  which  he  was  previously  liable,  but  to  which  he 
was  indifferent,  are  now  viewed  with  apprehension.  He 
becomes  fearful  of  the  dangers  opposing  him,  so  that  his 
courage  is  no  longer  automatic  but  forced.  According  as 
he  has  high  or  low  ideals,  is  more  or  less  intelligent,  he 


14 

feels  a  shame  before  his  fellows  as  a  coward,  or  feels  ill- 
treated  by  his  superiors  in  being  forced  to  continue  fighting. 
His  feeling  of  cowardice  may  lead  to  superhuman  efforts  of 
self-control,  but  these  lead  only  to  a  cumulative  increase  of 
his  fatigue.  Naturally  he  grows  mentally  and  nervously 
more  and  more  unstable,  but  is  prevented  from  leaving  the 
line,  either  by  his  superior  officers  or  by  his  own  shame  at 
the  thought  of  "going  sick,"  which  is  frequently  looked 
upon  as  a  sign  of  weaTcness.  Those  of  lesser  intelligence 
often  regard  their  terrors  as  indications  of  approaching 
insanity,  and  thus  another  worry  is  added  to  the  strains 
under  which  they  suffer.  Once  a  man  has  acquired  this 
unhappy  condition  any  trifling  accident,  such  as  a  mild 
concussion  from  an  exploding  shell,  or  some  particularly 
unpleasant  experience,  may  cause  a  final  break  and  lead  to 
such  an  exaggeration  of  symptoms  already  present  that  he 
becomes  totally  incompetent. 

It  is  not  unnatural  that  anyone  in  this  situation  should 
look  for  some  relief,  and,  unconsciously  at  least,  this  must 
be  a  powerful  factor  in  the  production  of  disabling 
symptoms.  In  many  cases,  after  more  or  less  of  these 
prodromal  difficulties,  symptoms  appear  that  seem  to  be 
specifically  directed  against  the  man's  capacity  to  fight. 

As  many  physicians  in  England,  previously  apathetic  or 
antagonistic  to  psychoanalysis,  now  admit,  the  general 
mechanisms  of  repression  of  emotionally  toned  ideas  with 
their  reappearance  when  repression  fails,  are  responsible 
for  the  production  of  the  symptoms  of  war  neuroses. 
Psychoanalysts  in  civilian  practice  claim  that  the  individ- 
ualistic tendencies  in  question  are  preponderantly  related  to 
the  sex  instinct.  In  war,  however,  this  does  not  seem  to 
be  the  case,  these  latter  tendencies  coming  into  play, 
apparently,  only  as  a  complication.  The  reason  for  this  is 
probably  to  be  found  in  the  fact  that  in  warfare  the  instincts 
of  self-interest  and  self-preservation,  which  are  equally  as 
primitive  and  basic  as  the  sex  instinct,  are  involved  in  a 
way  that  they  never  are  in  normal  civilian  life.  The 
psychological  factors  are  consequently  much  more  simple, 
and  it  may  be  that  this  explains  the  extraordinary  amena- 


15 

bility  of  the  war  neuroses  to  treatment.  Personality  studies 
of  many  of  the  cases,  however,  show  a  previous  weakness 
in  adaptability  that  is  confined  to  such  demands  as  are 
essentially  related  to  sex.  These  individuals,  although 
they  may  never  manifest  symptoms  directly  related  to  any 
erotic  tendencies,  are  nevertheless  apt  to  suffer  sooner  or 
more  severely  than  their  completely  normal  fellows.  The 
explanation  for  these  two  phenomena  is  perhaps  to  be  found 
in  the  fact  that  sex  adaptation  is  quite  the  most  difficult  of 
all  those  which  the  individual  has  to  make  in  modern 
civilization.  The  same  fundamental  weakness  exhibits 
itself  in  his  failure  to  respond  fully  to  the  most  trying 
demands  of  civilian  life,  namely,  those  of  sex  adaptation, 
and  in  his  inability  to  meet  the  demands  of  war.  In  other 
words,  the  neurotic  in  times  of  peace  may  have  his  symptoms 
on  account  of  poor  adaptation  in  the  sex  sphere,  but  this  is 
fundamentally  dependent  on  some  vague  constitutional 
defect  from  which  he  suffers.  It  is  this  defect  which  also 
makes  him  liable  to  lose  his  efficiency  in  the  unparalleled 
strain  of  modern  war.  One  makes  inquiry  into  a  patient's 
past  life,  therefore,  not  only  in  order  to  discover  what  there 
may  have  been  in  his  previous  character  which  would 
directly  affect  his  capacity  as  a  soldier,  but  also  to  gain 
some  rough  idea  of  how  resistant  he  had  previously  been  to 
the  most  disturbing  influences  of  life. 

Anxiety  States. 

The  term  ' '  Anxiety  States  ' '  is  chosen  to  designate  one 
of  the  two  clinical  groups  into  which  the  war  neuroses  fall, 
for  the  reason  that  anxiety  is  the  most  prominent  and  con- 
sistent feature  in  the  clinical  picture.  These  cases  bear 
most  resemblance  to  what  is  frequently  termed  ' '  neuras- 
thenia "  in  civil  practice,  but  it  is  thought  better  to  avoid 
this  term  in  the  present  instance  on  account  of  the  vague- 
ness which  almost  universally  exists  as  to  what  neuras- 
thenia is.  Unfortunately  the  term  has  been  used  to  include 
practically  every  neurosis. 

The  clinical  course  of  an  anxiety  state  is  as  follows:  the 
patient  is  a  man  who  may  or  may  not  have  had  a  past 


16 

history  of  abnormality.  The  existence  of  abnormality 
affects  the  clinical  course  of  his  neurosis  in  that  it  is  apt  to 
indicate  an  earlier  onset,  more  marked  symptoms  and  a 
longer  duration.  But  there  are  too  many  exceptions  to 
this  statement  to  make  it  more  than  a  generalization. 

When  the  civilian  enlists  or  is  commissioned,  he  at  once 
enters  into  a  totally  new  life,  and,  provided  he  is  a  tolerably 
normal  individual,  quickly  adapts  himself  to  it.  This  is 
demonstrated  by  his  eagerness  to  learn  his  new  duties,  his 
pleasure  in  his  accomplishment  as  training  progresses,  and 
in  an  increased  sociability.  It  is  frequently  found  that  an 
individual  who  has  been  rather  shy  will  make  more  friends 
after  entering  the  army  then  he  ever  did  before.  It  is,  of 
course,  unnecessary  to  state  that  training  almost  invaria- 
bly has  a  marked  effect  on  physique  in  the  direction  of 
improvement. 

The  mental  attitude  of  the  new  soldier  on  leaving  for  the 
front  is  of  some  interest.  The  majority  of  men  are  eager 
for  their  new  experiences  and  look  forward  to  active  service 
without  much  apprehension.  A  few,  however,  of  the  more 
introspective  type,  are  unable  to  keep  their  thoughts  away 
from  wounds  and  death;  some  with  a  distinct  fear  of  fail- 
ure, that  is,  a  fear  that  their  courage  may  not  be  equal 
to  the  demands  made  upon  it.  With  occasional  men  this 
apprehension  is  suflScient  to  precipitate  a  neurosis,  but  the 
clinical  features  of  this  are  more  apt  to  resemble  the  peace, 
than  the  war,  type,  and  none  are  included  in  this  report. 
It  is  important  to  note  that  some  momentary  disquietude  at 
this  stage  is  not  necessarily  indicative  of  coming  failure. 
There  are  men  who  approach  the  actual  battlefield  with 
considerable  misgiving,  but  are  surprised  to  find  how 
indifferent  they  quickly  become  to  the  dangers  they  meet 
there. 

The  first  actual  trial  which  the  recruit  usually  meets  is 
the  experience  of  being  shelled.  Naturally  the  intensity 
of  the  bombardment  varies  greatly,  and  if  the  shells  are 
falling  at  long  intervals  of  time  and  at  considerable  dis- 
tance, it  is  only  the  most  unstable  who  are  particularly 
affected.     Few,  if  any,  as  far  as  one  can  learn,  are  abso- 


17 

lutely  normal  on  introduction  to  a  heavy  bombardment. 
By  far  the  commonest  response  is  one  of  fear,  usually 
accompanied  with  the  idea  of  running  away,  which  the 
subject  himself  sees  to  be  absurd.  Although  the  men  may 
make  an  effort  to  hide  the  signs  of  this  fear,  they  are  so 
frequently  evident  under  initial  shelling  that  the  military 
authorities  count  on  their  appearance.  Their  presence  at 
this  time  is  no  indication  of  the  degree  of  indifference  which 
may  later  develop.  A  less  common  reaction  is  that  of 
excitement,  accompanied  even  with  a  kind  of  spurious 
elation.  The  man  has  a  tendency  to  make  facetious 
remarks  about  the  shells,  to  laugh  at  feeble  witticisms,  and 
very  often  feels  under  considerable  motor  tension,  there 
being  a  pressing  desire  to  do  something,  to  do  it  immedi- 
ately and  do  it  hard.  A  still  more  unusual  but  very  inter- 
esting reaction  is  that  of  slowness  or  languor  (which  may 
succeed  primary  fear).  This  may  be  accompanied  by  a 
depressive  affect  or  by  lethargy  so  extreme  that  the  indi- 
vidual will  lie  down  and  go  perforce  to  sleep  with  a  patho- 
logical indifference  to  the  danger. 

None  of  these  reactions  seem,  of  themselves,  to  be  indica- 
tive of  the  future  adaptability  of  the  soldier.  That  is 
determined  much  more  by  the  duration  of  these  symptoms. 
Most  men  recover  quite  soon  (a  matter  of  a  day  or  so)  and 
then  become  indifferent  to  the  possibility  of  being  hit,  and 
capable  of  philosophically  considering  the  chances.  This 
development  is  usually  accompanied  by,  or  is  the  result  of, 
learning  to  recognize  the  location  and  direction  of  the 
shells  by  the  sound  they  make  in  traveling  through  the 
air.  When  a  man  can  tell  from  the  sound  that  a  shell  is 
traveling  some  distance  over  his  head  and  will  fall  a  hun- 
dred yards  to  the  rear,  that  sound  has  no  further  terrifying 
effect  on  him. 

If  the  primary  bombardment  be  sufficiently  heavy,  the 
soldier  sees  his  first  casualties,  and  it  is  a  rare  man  who  is 
not  struck  with  horror  at  the  sight  of  the  mangled  remains 
of  his  comrades.  The  man  who  is  going  to  make  a  good 
soldier,  however,  quickly  becomes  accustomed  to  this. 
Similarly,  there  may  be  an  initial  inhibition  with   horror  at 


18 

tlie  thought  of  inflicting  wounds  on,  or  killing,  an  opponent, 
but  this,  too,  is  a  temporary  phase.  Individuals  who  can  not 
recover  fully  from  their  initial  fear,  horror,  or  reluctance 
to  inflict  injury,  never  build  up  that  sublimation  which  we 
have  described,  and  so  are  poorly  adapted  to  a  soldier's 
life.  These  men  are  very  quickly  fatigued  and  develop 
disabling  symptoms. 

The  first  sign  of  an  approaching  neurosis  is  fatigue.  The 
word  sign,  rather  than  symptom,  is  used  because  fatigue  as 
such  is  a  condition  which  is  completely  removed  by  rest, 
and  rest  of  quite  brief  duration.  For  the  neurosis,  fatigue 
is  of  importance,  as  it  is  the  almost  universal  occasion  of 
the  dissatisfaction  with  his  work  which  leads  to  a  breaking 
down  of  the  soldier's  adaptation  and  the  development  of  more 
permanent  symptoms.  The  conditions  producing  fatigue 
are  both  physical  and  mental.  Those  on  the  physical  side 
are  the  obvious  ones  of  long  hours  of  duty,  combined  often 
with  irregularity  of  meals,  shortness  of  water,  exposure  to 
extremes  of  temperature,  constant  wetting,  etc.  Although 
these  factors  need  no  detailed  consideration  on  account  of 
their  obviousness,  their  importance  in  producing  fatigue 
can  not  be  too  strongly  emphasized.  Important  as  they  are, 
however,  they  are  probably  of  less  influence  in  the  produc- 
tion of  neurotic  fatigue  than  are  the  purely  mental  in- 
fluences. The  most  common  and  important  of  these  is  the 
strain  of  continuing  in  a  dull  routine  that  demands  a  con- 
stant alertness,  a  speediness  of  decision,  complete  self- 
confidence  and  a  spontaneous  eagerness.  And  this  mental 
attitude  must  be  maintained  hours,  even  days,  on  end,  with- 
out sleep,  often  without  the  distraction  of  food,  and  in  the 
face  of  constant  danger.  Other,  more  personal,  factors 
contribute  to  the  development  of  fatigue.  A  man,  for 
instance,  may  be  placed  under  the  authority  of  some  one 
who  is  antagonistic  to  him  and  makes  everything  as  diffi- 
cult as  possible.  This  naturally  leads  to  distrust,  and  once 
a  man's  confidence  is  lost  in  his  superiors  it  is  soon  impossi- 
ble for  him  to  disregard  the  strain  under  which  he  suffers. 
Many  men,  too,  have  peculiarities  that  make  them  suscep- 
tible to  particular  discomforts.     Such  things  as  the  presence 


19 

of  vermin,  and  the  frequency  of  bad  odors,  particularly 
where  there  are  many  unburied  bodies,  are  factors  of  no 
mean  importance  in  slowly  disheartening  the  soldier.  In 
fact,  one  can  safely  say  that  in  view  of  the  many  external 
physical  diflSculties,  a  soldier  can  be  kept  in  the  best  men- 
tal condition  only  when  he  is  not  irritated  by  things  which 
affect  his  special  sensibilities,  and,  most  important,  when 
he  feels  sociallj^  comfortable  with  his  mates.  Not  infre- 
quently the  death  of  a  close  friend  or  comrade  may  be  the 
signal  for  the  stress  of  warfare  to  make  its  effects  known. 

The  above  views  present  this  neuro-ps^'chic  fatigue  as  a 
product  of  environmental,  or  of  mental,  factors.  It  must 
be  mentioned,  however,  that  other  views  are  held  on  this 
matter.  When  these  patients  are  finally  brought  to  a  hos- 
pital, it  is  often  found  that  they  have  a  low  blood- pressure. 
Temporary  symptoms  indicative  of  thyroid  disturbance  are 
also  seen  not  infrequently.  Some  students  of  ' '  shell  shock  ' ' 
have  therefore  made  the  claim  that  the  fundamental  and 
primary  cause  of  the  neuroses  lies  in  the  ductless  glands. 
They  consider  that  the  patients  have  succumbed  to  the 
strain  of  warfare  because  their  endocrinic  functions  were 
less  stable  than  those  of  their  fellows.  Considering  that 
the  vast  bulk  of  these  men  have  never  shown  any  symptoms 
earlier  in  their  lives  of  internal  secretion  disease,  this  is  prob- 
ably too  sweeping  a  statement  to  be  accepted  as  such.  It 
must  be  borne  in  mind,  however,  that  some  chemical  change 
is  probably  present  in  neuro-psychic  fatigue.  The  poison — 
whatever  it  is  that  affects  the  central  nervous  system — may 
easily  be  the  product  of  some  endocrinic  reaction  to  abnor- 
mal conditions.  This  opens  up  an  important  and  not  un- 
promising field  for  research.  Civilian  life  does  not  favor 
the  development  of  fatigue  to  anything  like  the  same  extent 
as  does  the  stress  of  war.  Consequently,  any  chemical 
changes  must  be  present  in  a  greater  degree  than  in  the 
milder  states  of  mere  ' '  tiredness  ' '  which  we  meet  in  times 
of  peace.  Therefore,  what  has  heretofore  remained  undis- 
covered might  now  be  found  to  the  immense  benefit  of 
neuropathology . 

It  can  readily  be  seen  that  the  more  in  the  mental  sphere 


20 

a  man's  responsibilities  lie,  the  more  quickly  will  he  be 
affected,  and  it  is  a  striking  fact  that  anxiety  conditions  in 
the  pure  state  occur  almost  exclusively  among  officers.  It 
is  their  task,  not  merely  to  keep  their  own  feelings  in  sub- 
jugation, but  to  inspire  the  men  beneath  them  with  courage 
and  enthusiasm. 

The  evidences  of  fatigue  are  almost  exclusively  in  the 
mental  sphere.  It  goes  without  saying  that  there  is  a  sub- 
jective feeling  of  weariness.  This,  however,  is  so  common 
and  so  easily  produced  that  it  is  of  no  especial  significance. 
What  one  can  term  fatigue  in  a  clinical  sense  appears  when 
other  symptoms  develop.  These  are  a  feeling  of  tenseness, 
a  restless  desire  for  action  or  distraction,  irritability,  diffi- 
culty in  concentration,  and  a  tendency  to  start  at  any 
sudden  sound  (without  fear),  the  sound  being  usually  that 
of  exploding  shells.  This  reaction  of  nervous  starting  is  so 
common  that  it  is  universally  known  by  the  officers  and 
men  as  "jumpiness."  There  is  usually  a  slight  improve- 
ment in  the  feeling  of  weariness  toward  night,  as  a  certain 
degree  of  excitement  accumulates  which  enables  the  indi- 
vidual to  disregard  his  difficulties. 

The  nocturnal  symptoms  are  even  more  distinctive. 
There  is  great  difficulty  in  getting  to  sleep,  with  a  long 
period  of  hypnagogic  hallucinations.  Whatever  has  been 
the  dominating  experience  of  the  day  appears  in  trouble- 
some vision  before  the  e3^es  of  the  soldier,  who  although 
knowing  that  what  he  sees  is  not  actually  there,  is  still  un- 
able either  to  go  to  sleep  or  to  awaken  himself  sufficiently 
to  banish  the  visions.  The  only  emotional  reaction  is  a 
feeling  of  irritation  with  restlessness.  Fatigue  as  such  does 
not  seem  to  produce  fear.  When  sleep  does  come,  it  is 
often  troubled  by  repeated  dreams  of  the  occupational  type 
where  the  soldier  is  trying  to  do  whatever  was  his  task 
during  the  day,  is  having  constant  difficulty  and  meeting 
with  no  success  in  accomplishment.  The  sleep,  too,  is  fre- 
quently interrupted  by  the  man  suddenly  awakening  with  a 
jump,  although  he  is  not  conscious  of  this  wakiug  being  the 
result  of  any  incident  in  his  previous  dream.  As  a  result, 
he  gets  many  less  hours  sleep  than  he  expected,  and  little 


21 

benefit  from  the  sleep  he  does  achieve.  He  awakes  in  the 
morning-  more  tired  than  when  he  lay  down,  feeling  slow 
and  unwilling  to  assume  the  duties  to  which  he  has  to  force 
himself. 

When  this  situation  has  continued  for  some  time  and 
become  cumulatively  worse,  fear,  as  has  been  said,  develops, 
and  also  horror  of  the  sights  around  him.  Both  of  these 
are  signs  that  the  "war  sublimation"  has  failed.  The 
soldier  finds  himself,  when  alone  and  not  mentally  occupied 
with  his  duty,  thinking  of  the  horrible  sights  he  has  seen. 
He  dwells  obsessively  on  the  difficulties  which  surround 
him,  on  the  frictions  he  may  have  with  brother  or  superior 
officers,  and  can  not  keep  his  mind  away  from  the  possi- 
bility of  injury.  It  is  interesting  to  note  that  the  British 
soldiers  are  singularly  free,  at  this  stage,  from  homesickness, 
although  the  Canadian  troops  are  very  liable  to  it.  This  is 
presumably  the  result  of  the  longer  distance  from  home  of 
the  latter  and  the  impossibility  of  return  within  the  near 
future. 

A  man  in  this  condition  is  very  apt  to  find  a  certain  ex- 
ternalization  of  his  difficulty  in  thinking  about  war  in 
general,  and  there  are  probably  no  more  fervid  pacifists  in 
existence  than  many  of  the  men  who  are  conscientiously 
fighting  day  after  day.  Many  of  them  acquire  with  their 
reluctance  to  bloodshed  such  a  pity  for  the  enemy  that  they 
find  it  difficult  to  fight  effectively.  At  this  stage  when  fear 
is  developing,  a  man  begins  to  lose  his  judgment  concern- 
ing the  direction  of  shells.  At  first,  he  feels  frightened 
when  he  hears  the  shell  coming,  although  he  knows  it  is  not 
going  to  land  where  he  is.  Later,  he  loses  the  ability  to 
gauge  its  direction,  and  consequently  every  shell  seems 
aimed  at  him  personally.  Naturally  in  such  a  situation  a 
heavy  bombardment  becomes  almost  intolerable.  It  is 
necessary,  however,  particularly  for  the  officer,  that  all  signs 
of  fear  should  be  hidden,  and  to  his  other  difficulties  is  added 
the  fear  that  he  may  not  be  able  to  hide  his  fear — another 
factor  in  the  vicious  circle. 

Thus  afflicted,  the  soldier  now  has  ideas  of  escape,  the 
nature  of  which  has  considerable  influence  on  the  symp- 


22 

toms  to  follow.  There  are  three  practicable  avenues  of 
escape;  the  man  may  receive  an  incapacitating  wound,  he 
may  be  taken  prisoner,  or  he  may  be  killed.  One  who 
manifests  an  anxiety  state  is  always  one  with  high  ideals 
of  his  duty.  We  find,  therefore,  that  none  of  them  entertain 
the  hope  of  disabling-  wounds.  Nor  do  they  consciously 
seek  surrender,  but  it  is  interesting  that  the}''  not  infrequently 
dream  of  it  at  this  stage.  The  third  possibility  is  the  most 
alluring,  as  it  offers  complete  release  and  is  quite  compatible 
with  all  standards  of  duty.  It  is  not  unnatural,  therefore, 
that  many  of  these  unfortunates  who  are  constantly  obsessed 
with  fear  perform  most  reckless  acts.  Almost  universally 
there  are  thoughts  of  suicide,  and  many  of  the  men  thus 
afflicted  will  plan  different  methods  of  accomplishing  their 
own  deaths  in  ways  which  could  not  be  subsequently 
regarded  as  suicidal. 

When  once  the  desire  for  death  has  become  fixed,  a 
complete  breakdown  is  imminent.  This  breakdown,  as  a 
rule,  occurs  after  some  accident,  which  is  either  physical  or 
mental.  The  commonest  physical  accident  is  the  exposure 
to  the  explosion  of  a  shell,  which  either  produces  a  brief 
unconsciousness  by  concussion,  or,  possibly,  poisons  the 
individual  with  some  noxious  gas.  After  this  accident,  the 
neurosis  is  suddenly  established  in  an  incapacitating  form, 
or  if  the  fatigue  symptoms  have  just  begun,  they  are 
suddenly  very  much  worse. 

The  mental  accidents  should  properly  be  called  precipi- 
tating factors.  They  consist  of  psychic  traumata  such  as 
particularly  horrible  sights,  the  mangling  of  some  close 
friend,  or  the  killing  of  all  others  in  the  immediate  environ- 
ment. Occasionally  it  is  an  extremely  dangerous  situation, 
such  as  arises  when  a  company  is  isolated  in  an  advanced 
trench  and  subjected  to  a  pitilessly  methodical  bombard- 
ment that  seems  certain  to  kill  every  occupant  of  the  trench 
sooner  or  later.  A  very  frequent  occurrence  is  burial  with 
earth  thrown  up  by  an  exploding  shell.  Some  clinicians 
are  inclined  to  attribute  all  the  results  of  such  burial  to 
concussion,  whereas  a  more  thorough  examination  of  many 
patients,  who  have  been  buried,  reveals  the  fact  that  there 


23 

have  been  no  symptoms  developed  which  could  not  be  fully 
accounted  for  on  the  basis  of  mental  shock,  and,  on  the 
other  hand,  that  there  have  been  none  that  point  definitely 
to  concussion.  It  is  important  to  note  that  this  quite 
frequent  accident  produces  little  or  no  effect  on  the  normal 
individual,  but  is  extremely  trying,  if  not  actually  incapaci- 
tating to  the  soldier  who  has  begun  to  manifest  symptoms. 

Another  precipitating  factor,  that  is  obviously  purely 
mental,  is  the  disappointment  ensuing  on  a  refusal  of 
"leave"  from  the  trenches  when  that  has  been  expected. 
The  man  whose  ability  to  continue  fighting  has  been  put 
to  a  great  strain,  is  enabled  to  keep  going  by  the  thought 
that  there  is  a  definite  end  in  view.  When  this  end  is 
suddenly  and  indefinitely  postponed,  his  last  remaining 
source  of  encouragement  is  gone  and  he  collapses.  Simi- 
larly, when  the  soldier  is  sent  back  to  a  rest  camp  for  a 
short  stay  and  this  has  proved  insufficient  to  restore  his 
equilibrium,  the  order  to  return  to  the  front  line  may  cause 
the  sudden  development  of  incapacitating  symptoms. 

It  is  both  theoretically  and  practically  of  the  first  impor- 
tance to  recognize  that  actual  wounding  does  not  disable 
the  soldier  neurotically,  no  matter  what  his  mental  and 
nervous  condition  may  be.  This  is  really  not  difficult  to 
understand.  As  we  have  seen,  the  man  has  an  urgent 
desire  to  escape  from  an  intolerable  situation,  and  a  large 
part  of  the  motivation  of  the  symptoms  comes  directlj^  from 
this  wish.  A  wound  is  obviously  an  ideal  form  of  relief. 
So  true  is  this  that  it  is  said  to  be  a  common  occurrence  for 
a  soldier  who  has  had  a  foot  or  a  leg  blown  off,  to  dance 
about  on  the  remaining  one  shouting  with  joy  that  he  has 
got  a  "Blighty  one"  (Blighty  being  the  Tommies'  slang 
for  England;  that  is,  a  wound  which  will  take  him  home). 

The  acute  symptoms  of  the  neurosis  may  be  ushered  in 
with  a  stuporous  state.  As  I  have  said  before,  I  have  not 
enjoyed  an  opportunity  of  examining  cases  at  this  stage, 
and  so  must  rely  on  what  can  be  gained  from  the  patients' 
own  retrospects,  and  what  is  to  be  learned  from  others.  It 
seems  that  these  stuporous  states  that  ensue  suddenly  after 
concussion  or  some  mental  trauma  are  of  two  types,  organic 


24 

and  functional,  althoug^h  the  latter  may  slowly  emerge  from 
the  former.  The  organic  type  is  marked  by  a  true  loss  of 
consciousness,  followed  by  a  period  during  which  conscious- 
ness reappears  and  can  be  maintained  for  a  short  time,  only 
to  lapse  again.  This  ' '  dipping  "  may  endure  for  days,  even 
weeks.  While  conscious,  the  patient  is  extremely  confused, 
disoriented,  usually  complains  of  violent  headache,  is 
frequently  incontinent  and  may  have  to  be  catheterized. 
A  delirium  is  very  frequent,  the  content  of  which  is  constant 
aggression  on  the  part  of  the  enemy,  either  with  bayonets, 
bombs  or  shells,  against  which  the  patient  is  largely  or 
completely  powerless. 

The  functional  type  of  stuporous  state  may  be  ushered  in 
by  a  condition  which  apparently  expresses  the  acme  of  fear, 
the  patient  lying  with  dilated  pupils,  in  a  cold  sweat,  with 
shallow  breathing,  incapable  of  any  voluntary  movement, 
and  often  trembling  violently.  Following  this,  there  is  a 
phase  when  voluntary  movement  is  possible,  during  which 
he  is  dazed,  inactive,  confused  and  amnesic,  and  may 
use  gestures  in  place  of  speech.  Myers  thinks  that  the 
"unconsciousness ' '  of  which  so  many  patients  subsequently 
tell  may  really  be  this  stuporous  state.  Unfortunately  he 
attempts  no  discrimination  between  organic  and  functional 
symptoms  in  these  conditions. 

While  still  in  a  stuporous  state,  the  patient  may  suffer 
from  hallucinations  concerning  which  he  is  amnesic  or 
confused  later.  It  is  only  the  more  severe  cases,  of  course, 
which  show  marked  or  prolonged  symptoms  of  stupor.  In 
others,  the  hypnagogic  hallucinations  of  which  we  have 
spoken  pass  over  into  somewhat  similar  visions,  which  are 
now  accompanied  by  fear.  That  is,  in  place  of  a  repetition 
of  the  day's  work,  in  the  visions  on  going  to  sleep,  the 
patient  sees  soldiers  advancing  against  him  with  bayonets, 
throwing  bombs  at  him,  feels  mines  exploding  beneath  his 
feet,  or  he  hears  shells  coming  shrieking  toward  him. 
Insight  as  to  the  reality  of  these  visions  varies.  Occasion- 
ally it  is  constant.  More  often  it  is  applied  with  some  effort 
on  the  part  of  the  patient,  whereas  it  is  quite  unusual  for  it 
to  be  consistently  absent.     Any  sudden  sound,  such  as  a 


25 

door  slamming,  is  interpreted  as  the  explosion  of  a  shell, 
with  consequent  terror.  The  patient  jumps  with  fright, 
although  he  usually  realizes  very  quickly  the  real  nature  of 
the  sound. 

In  his  preliminary  symptoms,  the  patient,  as  a  rule,  may 
have  been  bothered  with  dreams  of  the  occupational  type, 
but  has  had  few,  if  any,  nightmares.  Once  the  neurosis 
reaches  this  acute  stage,  however,  sleep  becomes  torture 
owing  to  the  violence  of  nightmares.  These,  like  the 
hallucinations  have  a  purely  war  content,  the  setting  of 
which  is,  as  a  rule,  the  section  of  the  line  in  which  the 
patient  has  last  been,  or  that  section  in  which  he  may  have 
been  subjected  to  most  severe  strain.  The  exact  nature  of 
the  injuries  which  seem  imminent  in  the  dreams,  naturally 
varies  with  the  type  of  fighting  in  which  the  man  has  been 
engaged.  The  enemy  is  throwing  bombs  at  him,  which 
explode  at  his  feet,  he  is  about  to  be  bayoneted,  he  is  shot 
down  in  an  aeroplane  or  shells  are  raining  upon  him. 
Unlike  dreams  in  times  of  peace,  no  amount  of  cross- 
questioning  can  produce  any  details  which  would  indicate 
that  there  is  any  inaccuracy  in  the  delineation  of  the  normal 
environment.  That  is,  the  soldier  is  always  in  France,  he 
is  always  in  a  trench,  his  comrades  are  always  his  natural 
comrades,  nothing  is  distorted  except  that  he  is  invariably 
powerless  to  retaliate,  and  his  fear  is  infinitely  greater  than 
it  ever  is  while  he  is  awake  in  a  situation  at  all  similar. 
This  last  point  is  quite  intere.sting  psychologically.  Patients 
who  have  these  dreams  while  still  in  the  trenches  may  be 
completely  paralyzed  with  fear  in  their  dreams,  and  yet  be 
capable  of  performing  their  duties  diiring  the  da}^  with  few 
signs  of  nervousness;  occasionally  they  are  even  totally  free 
from  fear  during  the  day. 

The  patient  is,  of  course,  awakened,  as  in  the  civilian 
nightmares,  in  a  cold  sweat  of  terror;  frequently  he  awakes 
screaming.  As  even  a  few  minutes'  sleep  means  the  appear- 
ance of  such  a  nightmare,  there  is  added  to  his  previous 
difficulty  in  falling  to  sleep,  a  fear  of  sleep,  and  this  reduces 
his  actual  rest,  obtained  without  sedatives,  to  a  very  small 
amount.  In  fact,  patients  may  go  for  some  weeks  getting 
only  a  few  minutes  actual  normal  sleep  any  night. 


26 

Naturally  then,  the  fatig-ue  from  which  he  previously 
suffered  is  greatly  increased.  It  is  particularly  in  evidence 
in  the  morning-,  improving  somewhat  as  the  da^^  goes  on, 
and  apt  to  be  much  worse  again  by  night.  Blood-pressure 
may  be  quite  low  according  to  some  observers.  Some  have 
found  this  so  reg-ularly,  and  have  seen  it  rise  again  so 
consistently  with  improvement,  that  they  have  concluded 
that  there  is  a  primary  disturbance  in  the  glands  of  internal 
secretion.  It  is  not  unlikely  that  a  change  in  endocrinic 
functions  determines  the  low  pressure,  but  the  evidence 
seems  to  point  toward  this  change  being  secondary  to 
fatigue  (or  concussion).  It  must  be  borne  in  mind  that  the 
degree  of  fatigue  developed  in  active  warfare  is  incompar- 
ably greater  than  anything  we  ever  see  in  times  of  peace, 
and  that  a  low  blood-pressure  is  therefore  to  be  expected. 
Patients  in  the  acute  phases  of  the  neurosis  are  frequently 
subjected  to  photophobia.  Tremors  are,  I  believe,  always 
present.  These  occur  most  frequently  in  the  hands  and 
arms,  but  may  appear  in  any  part  of  the  body.  They  are 
present  both  at  rest  and  on  voluntarj^^  movement,  the  latter 
being  much  more  marked.  There  is  also  sometimes  a  slight 
ataxia  which  is  never  really  disabling.  Both  tremors  and 
ataxia  are  prone  to  be  much  exaggerated  when  attention  is 
directed  to  them.  Cyanosis  of  the  hands  and  feet  is 
frequently  observed,  but  perhaps  not  more  often  than  in 
soldiers  who  have  no  neurosis,  but  have  been  exposed  to 
the  inclemencies  of  the  weather  during  many  winter  months. 

Symptoms  suggestive  of  disturbance  of  the  thyroid  gland 
are  very  frequent,  but  usually  of  short  duration.  The  ej'-es 
protrude  slightly,  and  the  upper  eyelid  may  lag  behind  the 
eyeball  on  looking  downward;  the  pulse  is  rapid,  excessive 
sweating  is  extremely  common,  and  sometimes  there  is  a 
slight  enlargement  of  the  thyroid  gland.  Headaches,  rarely 
of  extreme  violence,  are  common. 

Objective  mental  symptoms  are  shown  occasionally  by 
tics,  such  as  blinking  the  eyes,  or  a  grimace  accompanied 
by  a  withdrawal  of  the  head,  suggesting  the  starting  back 
from  something  unpleasant. 

Histories  of  these  patients  sometimes  state  that  they  have 


27 

been  subject  to  hysterical  "fits,  "  so  that  epilepsy  has  been 
considered.  Although  unable  to  observe  any  of  these  at- 
tacks myself,  I  have  carefully  questioned  a  number  of 
patients  who  have  had  them,  and  from  their  account  I 
should  be  inclined  to  believe  that  they  were  not  convulsions, 
in  any  sense  of  the  word,  but  much  more  like  tantrum 
reactions,  and  similar  to  the  performances  of  a  child  who 
lies  on  the  floor  and  kicks  when  particularly  upset. 

The  facial  expression  of  many  anxiety  cases  is  suffi- 
ciently typical  for  a  diagnosis  to  be  made  by  mere  inspection. 
The  face  is  drawn,  showing  signs  of  fatigue,  while  the 
emotional  strain  is  exhibited  by  chronic  frowning  with  con- 
siderable wrinkling  of  the  forehead.  The  patients  look  as 
if  they  were  under  great  strain,  and  maintaining  control  of 
themselves  with  effort.  The  expression  suggests  a  chronic 
mental,  rather  than  physical,  pain. 

As  most  of  these  patients  are  kept  in  bed  for  some  time, 
they  are  apt  to  be  weak  on  getting  up,  and  as  a  result  find 
themselves  unsteady  on  their  feet  when  they  attempt  to  walk. 
As  a  rule,  this  is  recovered  from  quite  quickly.  Occasion- 
ally, however,  the  staggering,  uncertain  gait  with  coarse 
tremors  of  the  feet  and  legs,  which  is  natural  to  a  weak- 
ened patient,  becomes  with  all  the  symptoms  exaggerated, 
a  chronic  gait.  This  is  rare  in  officers  but  more  common 
among  privates. 

There  is  an  interesting  feature  of  the  mental  state  of  these 
patients,  not  at  all  obvious,  but  subjectively  painful,  and 
one  that  has  considerable  effect  on  the  course  of  the  disease 
when  it  is  well  marked.  As  has  been  said,  these  men,  while 
still  in  the  firing  line,  are  apt  to  think  more  of  themselves 
than  they  previously  had  thought,  and  consequently  to  get  out 
of  touch  with  their  fellows.  This  latter  tendency  is  almost 
universally  present  when  the  neurosis  is  firmly  established. 
The  patient  suffers  considerably  from  a  lack  of  sociability, 
and  of  spontaneous  affection.  This  is  probably  due,  in  part, 
to  a  sense  of  un worthiness  which  develops  with  a  feeling  of 
cowardice.  As  in  almost  any  neurosis,  there  is  consider- 
able introversion.  Many  a  patient  wants  to  be  alone,  and, 
although  he  is  always  capable  of  making  a  good  impression 


28 

socially  in  a  formal  way,  he  finds  it  difficult  to  exhibit  any 
signs  of  affection.  The  man  who  is  visited  by  his  mother, 
his  wife,  or  his  sweetheart  is  a  disappointment  both  to  him- 
self and  to  his  visitor  in  that  it  is  impossible  for  him  to  give 
any  convincing  proof  of  his  affection.  This  finds  expres- 
sion physically  in  a  painfully  obvious  way  through  the 
symptom  of  impotence,  which  is,  so  far  as  I  have  been  able 
to  learn,  universally  present  in  the  anxiety  state,  either  as 
such  or  in  the  form  of  its  equivalent,  lack  of  erotic  feeling. 
Even  in  quite  mild  cases  it  occurs,  and  its  demonstration 
may  be  a  distinct  shock  to  the  patient.  More  frequently  no 
attempt  at  intercourse  is  made,  through  lack  of  desire. 

These  symptoms  continue  acutely  for  a  few  weeks  in  most 
cases,  sometimes  for  months  in  the  more  severe  neuroses. 
All  the  more  obvious  symptoms  tend  to  abate  gradually  with- 
out particularly  painstaking  treatment.  The  dreams  grow 
less  frequent,  and  usually  disappear.  Quite  frequently  the 
content  changes  when  the  patient  has  been  away  from  the 
trenches  for  some  time.  Distortions  occur  whereby  the  set- 
ting comes  to  include  more  of  the  normal  peace  environment. 
For  example,  the  patient  may  begin  to  have  normal  dreams 
of  civilian  life  which  will  be  suddenly  interrupted  by  the 
appearance  of  the  enemy  with  bombs  or  bayonets.  A  man 
may  be  playing  golf,  when  the  foe  suddenly  appears  on  the 
green.  A  very  interesting  change  of  content  occurs  occa- 
sionally and  marks  a  radical  emotional  change.  For  some 
time  dreams  will  proceed,  in  which  the  enemy  is  invariably 
successful  and  the  dreamer  powerless.  Then  the  dreamer 
begins  to  show  fight,  and  for  some  nights  may  struggle, 
although  still  defeated.  Next,  the  battle  becomes  a  draw. 
Finally,  the  dreamer  begins  to  get  the  upper  hand  and  is 
able  to  enjoy  the  fight  of  which  he  dreams,  because  he  in- 
variably punishes  the  enemy.  Such  a  sequence  augurs  well, 
of  course,  for  the  man's  further  adaptability  in  the  firing 
line.  When  improvement  begins,  the  fatigue  lessens  suffi- 
ciently for  the  patient  to  leave  his  bed  and  indulge  in  mild 
activities  about  the  hospital.  He  is  surprised,  however,  to 
find  how  quickly  he  becomes  tired,  even  exhausted,  when 
he  goes  through  the  streets,  or  attempts  to  play  some  game. 


29 

But,  unless  there  are  other  complications,  this  phase  of 
fatigability,  rather  than  chronic  fatigue,  is  quickly  passed. 

The  constant  apprehensiveness  which  persists  throughout 
the  day  in  the  acute  stages,  disappears,  but  in  its  place  there 
remains  a  good  deal  of  "  jumpiness."  In  the  earlier  stages 
a  sudden  noise  is  interpreted  as  an  explosion.  Then  the  real 
nature  of  the  sound  is  instantaneously  recognized,  but  the 
patient  is  frightened,  which  suggests  that  unconsciously  the 
sound  is  still  regarded  as  a  shell.  Later  the  habit  of  start- 
ing at  any  sound  persists  without  any  fear.  That  this  is 
purely  a  neurotic  habit,  is  demonstrated  by  such  instances 
as  the  following:  I  was  talking  to  a  patient  when  he  moved 
to  knock  some  ashes  from  a  cigarette  into  a  small  bowl. 
While  his  hand  was  approaching  the  bowl,  a  door  slammed. 
The  patient  proceeded  to  execute  his  movement  quite  care- 
fully and  then  to  jump  violently,  although  more  than  a 
second  had  elapsed  between  the  sound  and  the  jump.  At 
this  stage  the  patient  can,  if  he  exerts  sufficient  effort,  train 
himself  to  remain  calm  when  sudden  noises  occur.  Quite 
frequently  the  patients  who  are  more  intelligent  can  remem- 
ber accurately  the  phases  of  development  and  disappearance 
of  this  symptom. 

The  patient  has  now  come  to  appear  objectively  normal, 
but  grave  defects  are  still  subjectively  present  to  interfere 
with  his  renewed  adaptation  to  trench  warfare.  He  finds, 
for  instance,  that  crowded  traffic  makes  him  excessively 
nervous.  He  is  fearful  that  his  taxicab  will  run  over  some 
one  in  the  street,  or  that  there  will  be  collisions.  He  finds 
himself  fearful  if  he  is  in  a  high  place,  or  looks  out  of  a 
window  some  distance  from  the  ground.  He  can  not  enter 
a  tunnel,  and  thunder-storms  terrify  him.  Perhaps  his  most 
distressing  symptom  is  his  feeling  of  incompetence  and  his 
lack  of  desire  to  return  to  the  front.  He  is  a  subject  of  seri- 
ous mental  conflict.  He  knows  that  duty  calls  him  to  fight 
again,  and  that  he  ought  cheerfully  to  assume  these  duties, 
but  he  recognizes  that  he  is  a  coward,  feels  great  shame  over 
this,  and  is  even  more  ashamed  of  the  lack  of  desire  to  do 
his  bit.  It  is  this  final  phase  which  may  be  indefinitely 
prolonged  if  appropriate  psychological  treatment  is  not 
available. 


30 

When  acute  symptoms  subside,  complications  are  prone 
to  appear.  It  would  not  be  surprising  to  any  one  familiar 
with  the  psychology  of  the  neurotic  to  learn  that  the  disap- 
pearance of  obviously  incapacitating  symptoms  may  be  the 
signal  for  others  to  develop  which  would  make  return  to 
the  front  impossible.  Naturally,  these  complications  occur 
mainly,  if  not  exclusively,  in  those  who  have  before  the 
war  been  not  quite  normal.  A  man,  for  instance,  who  has 
previously  had  a  neurosis,  may  produce  his  old  symptoms 
again.  Captain  Rivers*  thinks  that  adaptation  to  war 
demands  a  repression  of  all  neurotic  tendencies  and  abnor- 
malities, which,  on  account  of  this  repression,  increase  in 
intensity,  and  therefore  reappear  with  unwonted  strength 
when  the  patient  has  been  absent  from  the  front  for  some 
time. 

A  frequent  complication  is  depression.  This  rarely,  if 
ever,  reaches  the  point  of  retardation.  It  is  much  more  a 
subjective  feeling  of  hopelessness  and  shame  for  incompe- 
tence and  cowardice.  Sometimes  the  depression  is  the 
accompaniment  of  obsessing  thoughts  about  the  horrors  the 
patient  has  seen,  and  about  the  horrors  of  war  in  general. 
Very  often  he  is  depressed  because  he  feels  that  he  is  not 
being  treated  well.  This  last  is  probably  a  development  of 
the  lack  of  contact  with  his  fellows  which  has  been  previ- 
ously enjoyed.  The  patient,  having  become  interested  more 
in  his  own  welfare  than  in  the  needs  of  the  army  or  the 
country,  is  prone  to  dwell  on  the  sacrifices  he  has  made  and 
the  obligations  of  the  state  to  him.  Such  patients  are  there- 
fore morbidly  interested  in  having  attention  paid  to  them. 
This  is  somewhat  different  from  ordinary  hypochondria,  in 
that  it  is  not  a  physical  symptom  for  which  the  patient  de- 
mands attention  so  much  as  it  is  himself,  his  personality, 
which  he  feels  to  be  neglected. 

The  diagnosis  of  this  neurosis  naturally  offers  very  little 
difficulty.  The  only  condition  with  which  it  could  be  con- 
fused is  malingering.  The  history  and  appearance  of  these 
patients  should,  however,  never  leave  much  doubt  in  the 
mind  of  the  physician.  Some  history  of  slow  onset  and 
gradual  dissatisfaction  is  invariably  present  in  those  cases 

*  Personal  communication. 


31 

who  do  not  break  down  after  physical  trauma.  Even  those 
who  have  suffered  from  severe  concussion  will  give  a  similar 
history,  although  it  may  be  reduced  to  the  presence  of  mild 
symptoms  for  a  short  time  before  the  accident.  I  was 
unable  to  find  a  single  case  of  pure  anxiety  who  did  not  give 
a  history  of  some  prodromal  difficulties.  The  concussion 
cases  also  show  signs  of  organic  disturbance  of  the  brain 
function,  which  are  diagnostic  (dipping  of  consciousness, 
confusion,  disorientation,  etc.).  The  malingerer  is  not  likely 
to  speak  frankly  about  his  gradually  increasing  terror, 
whereas  the  man  suffering  from  a  true  anxiety  neurosis  is, 
as  a  rule,  extraordinarily  open  and  frank  about  the  matter. 
The  appearance,  too,  of  drawn  face,  staring  eyes,  exhibit- 
ing obvious  distress,  combined  with  a  rapid  pulse  and 
excessive  sweating,  is  something  which  it  would  be  very 
hard  to  imitate  consciously.  Difficulty  in  eliminating 
malingering  occurs  almost  exclusively  with  the  conversion 
hysterias  rather  than  with  the  anxiety  neuroses. 

It  may  be  well  to  describe  in  somewhat  more  detail  the 
various  factors  of  importance  in  the  production  of  the 
anxiety  state  with  illustrative  cases. 

Mental  Make-up  :  There  are  certain  features  in  the  per- 
sonality study  which  are  more  or  less  directly  related  to  the 
capacity  of  the  individual  for  warfare.  It  goes  without 
saying  that  one  always  makes  inquiries  as  to  the  existence 
of  actual  nervous  breakdowns.  An  individual  who  has 
once  given  way  to  a  neurosis  is  obviously  more  likelj^  to  be 
unstable  than  one  who  has  not.  What  one  may  term 
neurotic  tendencies  rather  than  neuroses  must  be  searched 
for  diligently.  The  man  who,  as  a  child,  has  sviffered  from 
night  terrors  and  fear  of  the  dark  will  probably,  under  a 
strain,  be  more  apt  to  become  fearful  than  one  who  has  not. 
Similarly  an  individual  who  has  been  either  chronically,  or 
as  a  child,  afraid  of  thunder-storms,  is  apt  to  be  affected 
more  quickly  by  shell  fire,  as  the  noise  of  bombardment  is 
extremely  like  that  of  a  violent  thunder-storm.  A  man  with 
a  tendency  to  claustrophobia,  which  in  times  of  peace  may 
be  indicated  only  by  a  slight  feeling  of  faintness  in  an 
underground  train,  or  by  an  unusual  sensitiveness  to  the  bad 


32 

air  in  such  a  situation,  or  a  mild  feeling  of  discomfort,  is  apt 
to  be  fearful  of  dugouts  being  blown  in,  or  to  be  particularly 
afraid  that  he  may  be  buried  by  a  shell.  The  existence  of 
such  claustrophobic  tendencies  may  be  determined  by  ques- 
tioning as  to  symptoms  of  all  kinds  while  in  a  subway,  or 
by  finding  out  whether  the  patient  has  suffered  from  night- 
mares of  premature  burial,  or  of  being  enclosed  in  some 
small  space.  Great  sensitiveness  to  cruelty,  horror  of  blood- 
shed and  accidents,  discomfort  at  the  sight  of  animals  being 
killed,  unusual  sensitiveness  to  pain,  either  in  himself  or 
others,  are  all  indications  of  more  than  normal  difficulty 
which  the  soldier  may  have  in  accustoming  himself  to  the 
horrors  of  war.  Occasionally  this  abnormality  may  be 
expressed  in  a  morbid  fascination  for  the  horrible. 

Seclusiveness,  as  has  been  said,  is  important  in  that  it  is 
an  indication  of  general  lack  of  adaptability,  and  is,  of 
course,  more  likely  to  occur  in  an  individual  who  is  not  quite 
up  to  par  in  his  ability  to  meet  any  situation,  particularly 
one  such  as  war,  that  demands  the  highest  degree  of 
normality.  It  has,  however,  another  and  more  direct  impor- 
tance. The  soldier  who  is  not  naturally  sociable  has,  as  a 
consequence,  less  of  an  outlet  for  his  feelings  in  the  trenches, 
and  is  less  distracted  from  the  thoughts  of  the  painfulness 
of  his  situation  than  is  his  normal  companion.  As  a  result, 
he  becomes  more  quickly  a  prey  to  all  the  influences  that 
generate  fatigue  and  dissatisfaction. 

The  following  cases  exhibit  different  types  of  make-up 
and  the  effect  of  previous  abnormalities  on  the  development 
and  symptoms  of  anxiety  neuroses. 

Case  III.  The  patient  is  a  lieutenant,  of  25,  an  artist  before 
he  joined  the  army,  who  had  never  had  any  nervous  breakdown,  but 
with  the  rather  high-strung  sensitive  disposition  frequently  found  in 
those  who  adopt  this  profession.  As  a  child  he  had  frequent  night 
terrors,  which  disappeared  as  he  grew  older,  but  evidently  had  made 
quite  an  impression  on  him.  In  fact  he  spoke  of  the  dreams  which 
developed  in  his  neurosis  as  a  return  of  his  childish  nightmares. 
He  never  was  able  to  prevent  giddiness  when  he  was  in  an  especially 
high  place,  but  had  no  fear  of  thunder-storms.  He  was  abnormally 
sensitive  to  the  sight  of  blood,  and  more  sympathetic  than  is  usual. 
He  had  no  dreams  of  premature  burial,  but  as  a  child  remembers 
having  fear  of  being  shut  up  in  a  small  place.     In  his  adult  life  he 


33 

had  an  uncomfortable  apprehensiveness  when  on  the  underground 
railway,  and  was  positively  terrified  by  the  "  switchback  " — a  railway 
in  amusement  parks  that  dashes  suddenly  into  sepulchral  caverns. 

All  his  life  he  was  of  a  rather  retiring  and  self-conscious  disposition, 
but  constantly  struggled  against  it,  and  was  able  to  make  fair  adapta- 
tions. For  example,  he  played  the  usual  games  at  school,  and 
creditably,  too,  but  never  was  capable  of  abandoning  his  self-con- 
sciousness and  joining  in  with  the  usual  boyish  pranks  with  any 
great  enthusiasm.  He  was  similarly  rather  shy  with  girls,  but  did 
not  let  this  prevent  him  from  going  out  in  society,  although  he  had 
no  puppy  love  affairs.  He  fell  in  love  with  only  one  girl  and  married 
her  immediately  before  entering  the  army.  As  practically  all  of  his 
married  life  had  been  spent  away  from  home,  it  was  impossible  to  see 
how  well  he  would  have  adapted  himself  to  marriage. 

He  reacted  well  to  his  training  and  became  more  sociable  and  self- 
reliant.  When  he  arrived  in  France  and  came  under  shell  fire  he 
was  frightened,  and  although  he  recovered  to  a  certain  extent  from 
his  initial  terror,  he  never  was  capable  of  wholly  ridding  himself 
from  fear  of  shells. 

The  horrors  of  war  made  a  constant  impression  upon  him,  and 
afflicted  his  sensitive  nature  to  such  an  extent  that  he  never  could 
bring  himself  to  enjoy  the  fight  The  best  that  he  could  do  was  to  be 
unaware,  in  an  advance,  that  he  was  killing  men.  He  was  not  afraid 
of  machine  guns,  had  some  slight  fears  of  snipers,  but  found  a  con- 
stant strain  in  waiting  in  the  trenches  for  shells  to  come,  the  likeli- 
hood of  which  was  always  in  his  mind.  His  claustrophobic  tendencies 
appeared  in  that  he  was  afraid  of  the  dugouts  and  hated  to  go  into  them, 
although  they  offered  the  only  protection  from  bombardment.  He 
always  felt  that  a  shell  might  come  and  block  the  entrance  so  that  he 
would  be  buried  alive.     He  never  dreamed  of  this,  however. 

This  man  was  obviously  not  adapted  for  any  continued  stretch  of 
fighting,  and  as  a  result,  within  a  couple  of  months  of  reaching  the 
front  he  began  to  show  symptoms  of  fatigue  in  sleeplessness, 
hypnagogic  hallucinations,  and  a  good  deal  of  "jumpiness"  in  the 
daytime.  Fear  quickly  appeared,  and  then  his  condition  got  rapidly 
worse.  Being  a  man  of  high  ideals  as  to  his  duty,  he  made  great 
efforts  to  keep  all  signs  of  fear  from  his  men,  and  to  appear  absolutely 
intrepid  before  them.  In  this  he  succeeded,  but  only  to  produce  such 
a  strain  that  he  felt  after  a  few  weeks  that  it  was  only  a  matter  of 
time  before  he  would  have  to  give  up.  While  in  this  condition,  a 
shell  dropped  one  day  on  the  parados  and  threw  enough  dirt  into  the 
trench  where  he  was  standing  to  cover  his  legs  up  to  the  knees.  He 
became  absolutely  terrified,  although  physically  he  felt  no  effects 
whatever,  did  not  lose  consciousness  nor  become  at  all  confused.  It 
seems  not  unlikely  that  this  accident,  which  was  a  small  enough 
affair  in  the  light  of  his  daily  experiences,  represented  symbolic 
burial.     At  any  rate,    whatever  its   psychological    significance,    he 


34 

became  completely  unstrung  and  felt  that  it  was  absolutely  impossible 
to  continue  in  his  duties.  He  therefore  reported  sick,  and  the 
medical  officer,  observing  his  condition,  sent  him  to  the  hospital. 
That  night  he  dreamed  that  he  was  taken  prisoner  by  the  Germans, 
and  had  to  confess,  when  he  related  his  dream,  that  with  it  there  was 
a  certain  feeling  of  relief  in  that  he  was  by  this  event  free  from  all 
responsibilities  of  "  carrying  on. "  He  never  had  had  this  idea  during 
the  daytime,  however,  so  far  as  he  could  remember,  but  had  only 
wished  for  death. 

The  day  following  this  dream,  he  felt  still  worse,  more  fearful  than 
before  (although  he  was  out  of  danger)  and  extremely  sensitive  to 
noises.  That  night  terrifying  dreams  began.  These  were  always  of 
some  untoward  event,  the  most  frequent  of  which  was  that  the  enemy 
would  penetrate  his  trench,  and  rush  at  him,  with  bayonets,  one  of 
which  was  just  about  to  pierce  his  chest  when  he  would  awake  in  an 
agony  of  terror.  He  said  that  in  these  dreams  he  always  wanted  to 
scream  with  fright,  which  was  an  idea  which  would  never  occur  to 
him  in  the  daytime  in  the  trenches,  no  matter  how  frightened  he 
might  be. 

When  he  first  went  into  the  trenches  he  had  occasional  emissions 
during  sleep.  Once  his  symptoms  began,  these  ceased,  and  he  had 
no  erotic  thoughts  whatever.  The  latter  did  not  return  until  he  was 
nearly  recovered  from  his  neurosis. 

After  about  three  weeks  the  dreams  began  to  lessen  in  their  fre- 
quency, although  the  content  changed  not  at  all.  Finally  they  disap- 
peared. When  they  had  been  absent  for  about  a  week,  he  dreamed  one 
night  that  he  was  being  tied  down  by  some  soldiers  on  a  stretcher,  for 
what  purpose  he  did  not  know,  but  he  was  very  much  frightened  and 
was  trying  to  scream  when  he  awoke.  This,  of  course,  was  not 
related  directly  to  any  actual  experience  at  the  front,  and  it  remained 
an  isolated  dream. 

Physically  he  showed  some  fatigability  when  I  examined  him 
about  three  weeks  after  leaving  the  front.  He  had  prominent  eyes, 
a  rapid  pulse  and  some  sweating.  His  tremors  were  not  marked, 
and  did  not  endure  for  long.  His  was  a  case  where  a  few  weeks  rest 
in  bed,  without  other  treatment,  caused  all  the  obvious  symptoms 
to  disappear.  None  of  them,  in  fact,  had  ever  been  particularly 
severe,  except  the  dreams,  and  of  these  he  had  never  had  more  than 
one  or  two  in  any  one  night. 

This  history  is  rather  typical  of  the  patient  who  is  poorly 
adapted  to  fightin°f.  The  struggle  begins  at  the  first 
moment  of  entering  the  trenches,  and  the  mental  difficulties 
increase  out  of  all  proportion  to  the  physical  fatigue.  As  a 
result,  these  patients  are  apt  to  give  up  before  they  have 
struggled  long  enough  against  their  symptoms  to  exhaust 


35 

seriously  their  fund  of  nervous  energy.  The  symptoms, 
therefore,  do  not  become  so  intense,  nor  do  they  last  so  long 
as  they  do  with  those  who  are  normal  enough  to  become 
well  adapted  to  the  fighting  and  then  spend  weeks  and 
even  months  in  a  strenuous  effort  to  fight  their  symptoms 
after  the  "  break  in  compensation  "  has  set  in. 

To  get  such  a  patient  as  this  back  to  the  firing  line,  is, 
of  course,  a  good  deal  more  of  a  problem  than  to  relieve 
him  of  his  acute  symptoms. 

Case  IV.  The  patient  is  a  lieutenant  in  the  artillery,  23  years  of 
age.  He  was  always  high  strung  and  sensitive,  and  thinks  that  he 
would  have  been  definitely  seclusive  if  it  had  not  been  that  he  was 
put  to  school  at  10  and  left  there  until  he  was  nearly  20,  and  so  was 
forced  to  adapt  himself  to  boyish  life  before  the  habit  of  retreating  to 
the  protection  of  his  mother  and  family  had  become  fixed.  As  he 
grew  older  he  had  a  few  abortive  love  affairs  and  became  engaged  the 
first  year  of  the  war.  He  is  not  yet  married.  As  a  child  he  had 
night  terrors  and  a  constant  fear  of  the  dark  that  clouded  his  child- 
hood. As  he  grew  older,  however,  he  seems  to  have  become  much 
more  normal,  for  he  developed  no  phobias,  had  no  nightmares,  and 
none  of  the  usual  neurotic  sensibilities,  except  for  an  undue  horror  of 
cruelty  and  bloodshed. 

In  the  Spring  of  1914  he  had  an  attack  of  "neurasthenia  "  which  he 
thinks  was  somewhat  the  same  as  his  war  neurosis.  He  was  very 
much  disappointed  about  the  result  of  an  examination  which  he  had 
tried.  When  the  telegram  arrived  announcing  his  failure  he  "sort  of 
fainted,"  and  was  "hysterical  "  after  that.  For  some  weeks  he  slept 
poorly,  had  occasional  nightmares,  was  easily  fatigued,  easily  startled, 
and  felt  no  ambition.  This  continued  until  the  war  broke  out,  shortly 
after  which  he  joined  the  army  and  spent  over  a  year  in  training  for 
his  artillery  work.  He  rather  enjoyed  this,  became  quite  sociable 
with  his  brother  officers  and  looked  forward  keenly  to  going  to 
France.  He  was  rather  curious  to  know  what  it  would  all  be  like. 
In  his  first  shelling,  no  one  was  hit  in  his  immediate  vicinity.  He 
became  excited  and  enjoyed  it  in  a  sense.  A  few  weeks  later,  when 
on  a  road  back  of  the  lines,  a  shell  landed  in  the  engine  of  a  passing 
automobile  and  mangled  the  occupants  horribly.  This  upset  him  a 
great  deal  and  for  a  few  weeks  after  the  experience  he  stammered. 
(He  gave  a  long  and  unnecessarily  lurid  account  of  this  incident;  in 
fact,  in  all  his  recitals  there  was  evidence  of  a  morbid  fascination  for 
him  in  the  carnage  of  war. )  Following  this  experience  he  always 
had  some  fear  of  shells,  but  as  his  battery  was  miles  behind  the  front 
line  trenches  he  was  seldom  under  heavy  or  continuous  bombardment. 

After  seeing  what  a  shell  could  do,  he  always  had  a  certain  degree 
of  abhorrence  to  the  idea  of  killing  people,  but  his  victims  were  miles 


36 

away  and  he  kept  from  thinking  of  that  aspect  of  his  work  too  much, 
concentrating  his  mind  rather  on  perfecting  his  technical  skill  in 
gunnery  in  which  he  was  able  to  take  considerable  pride  and  satis- 
faction. He  was  quite  sure  that  he  never  could  be  brought  to  the 
point  of  running  a  man  through  with  a  bayonet.  He  continued  in 
this  position  for  six  weeks  and  then  went  home  to  England  on  leave. 
On  returning,  after  being  shelled  again  for  the  first  time,  he  stam- 
mered for  a  day  or  two,  but  quickly  recovered  from  this,  and  proceeded 
with  his  work  comfortably  enough  for  a  good  many  months.  He  was 
then  sent  to  Arras  (in  the  Spring  of  1917)  and  was  there  for  nine 
weeks  altogether.  The  fighting  grew  gradually  heavier.  He  became 
tired  with  the  constant  strain,  and  began  to  be  troubled  with  his  fear 
of  the  shells.  He  became  so  nervous  that  he  had  to  force  himself  to 
go  through  communication  trenches  that  were  under  shell  fire.  He 
slept  less  well,  having  difficulty  in  driving  the  thoughts  of  fighting 
from  his  mind,  and  had  occasional  dreams  of  running  the  battery,  but 
no  nightmares. 

For  the  last  four  or  five  weeks  the  feeling  grew  that  he  could  not 
keep  on  indefinitely  and  he  began  to  wish  that  a  shell  would  come 
and  end  it  all.  During  this  time  he  had  great  difficulty  in  putting 
from  his  mind  thoughts  of  the  wounds  and  death  he  was  occasioning 
in  the  German  lines.  Finally,  he  was  sent  to  an  observation  post  in 
No-Man's- Land  to  direct  the  fire  of  one  of  his  batteries.  He  went  out 
a  sap  about  fifty  feet  long  that  terminated  under  a  pile  of  sand-bags 
through  which  there  was  a  small  loophole  for  observation.  The 
Germans,  evidently  suspecting  that  an  observer  might  be  there, 
began  to  shell  this  spot  pitilessly.  The  patient  remained  for  some 
minutes  with  the  shells  bursting  all  around,  and  then  retired  to  a 
dugout  for  about  a  quarter  of  an  hour.  Having  recovered  his  courage, 
he  returned  to  his  post  and  made  the  necessary  observations,  although 
a  great  many  shells  were  still  falling.  He  thought  that  he  might 
have  received  some  slight  concussion  because  his  head  ached  a  little, 
but  otherwise  he  felt  fairly  comfortable.  He  was,  however,  very 
much  strung  up  by  his  efforts,  and  a  half  hour  later  when  he  returned 
to  his  battery  he  fainted.  The  unconsciousness,  if  it  was  complete, 
lasted  only  a  minute  or  so,  but  when  he  came  to  he  was  extremely 
fearful  and  so  emotionally  upset  that  he  was  sent  back  to  a  hospital  at 
once.  There  he  began  to  have  the  usual  terrifying  nightmares,  in 
his  case  always  of  being  shelled.  On  account  of  his  poor  sleep  he 
was  given  sedatives  very  freely,  the  effect  of  which  was  to  produce 
some  sleep,  it  is  true,  but  to  make  his  nervous  control  very  much  less. 
As  a  result  he  got  into  a  state  where  he  was  almost  constantly  shaking 
with  violent,  coarse  tremors,  and  apt  to  show  most  dramatic  exhi- 
bitions of  fear  when  the  slightest  noise  occurred.  He  stammered  a 
good  deal,  but  mainly  when  excited  by  examination,  for  he  could 
speak  quite  calmly  and  consistently  for  several  minutes  without  any 
hesitation.     When  under  observation  he  frequently  showed  a  peculiar 


37 

tic.  His  lips  wovild  shut  tight,  with  the  corners  of  his  mouth  drawn 
back  and  up,  his  nose  would  be  raised  with  a  "pug"  expression,  both 
of  which  movements  were  coincident  with  a  good  deal  of  blinking 
and  a  slight  retraction  of  the  head.  He  seemed  to  be  unaware  of 
these  contortions,  but  when  they  were  described  to  him  he  said  that 
those  were  the  movements  of  his  face  and  head  when  a  shell  burst 
and  threw  up  earth  near  him,  which  seemed  as  if  it  would  fly  in  his 
face.  With  this  explanation,  it  was  at  once  probable  that  the 
symptoms  had  developed  from  such  actions  of  shrinking  and  disgust, 
for  the  expression  of  his  face  accurately  showed  these. 

After  six  weeks  in  a  general  hospital,  where  he  was  subjected  to  a 
good  deal  of  annoyance  from  the  noises  of  busy  wards  and  the  sights 
of  many  wounded  men,  he  was  transferred  to  a  special  hospital  in 
England.  Here,  under  the  influence  of  complete  quiet  and  isolation, 
his  symptoms  very  largely  subsided  in  a  matter  of  a  couple  of  weeks. 
His  dreams  disappeared  altogether,  but  he  remained  for  a  month 
during  which  time  I  saw  him  occasionally,  still  prone  to  develop 
tremors,  grimaces  and  signs  of  emotional  instability  when  under  close 
observation,  or  when  startled  by  sudden  noises.  He  was,  however, 
anxious  to  understand  the  psychological  mechanisms  of  his  symptoms, 
and  made  promising  efforts  to  gain  complete  control  over  himself. 

Cask  V.  The  following  case  gives  an  excellent  example  of  the  long 
fight  which  a  patient  may  make  against  his  symptoms,  a  struggle  that 
reflects  more  credit  on  the  individual  than  many  exhibitions  of 
sudden  and  unconscious  courage.  The  patient  is  a  lieutenant  in  the 
artillery,  who  joined  the  army  in  the  Spring  of  1915.  He  was  always 
given  to  worrying  about  trifles,  and  to  feeling  that  he  had  made 
mistakes.  He  was  self-conscious,  but  with  effort  became  steadily 
more  sociable  as  he  grew  older.  As  a  child  he  was  painfully  shy  and 
fearful  of  his  capacity  to  do  anything.  With  adolescence  he  became 
more  normal  in  this  respect  and  had  many  puppy  love  affairs,  and 
more  serious  ones,  too,  for  he  was  finally  married  at  the  time  he 
joined  the  army.  Having  seen  little  of  his  wife,  he  has  had  no 
change  of  outlook  as  the  result  of  this  marriage. 

As  a  small  boy  he  was  afraid  of  the  dark.  He  began  reading  when 
very  young,  and  turned,  boy-like,  to  books  of  adventure.  When 
night  came,  he  would  lie  in  the  dark  and  people  it  with  imaginations 
that  would  become  very  fearful.  He  has  no  memory,  however,  of  actual 
nightmares.  He  has  always  been  uncomfortable  and  disturbed  during 
thunder-storms,  although  not  exactly  afraid.  He  invariably  suffered 
from  giddiness  in  high  places,  but  has  had  no  claustrophobic  tenden- 
cies, and  very  few  nightmares  of  any  kind.  Cruelty  and  bloodshed 
were  always  repulsive  to  him.  As  a  boy,  he  played  "Indian  "  a  great 
deal  with  his  brothers.  The  older  brothers  used  to  ambuscade  him 
and  scare  him  tremendously,  even  though  he  knew  what  was  coming. 
His  shyness  kept  him  from  playing  team  games  as  a  boy,  but  when  he 
was  older  he  took  up  tennis,  golf  and  walking,  although  music  and 


38 

reading  were  always  his  main  interests.  When  he  was  16,  one  of  his 
brothers  died  of  tuberculosis  at  the  age  of  23.  A  couple  of  years  later, 
another  brother  died  of  the  same  disease  at  the  same  age.  The  patient 
became  so  obsessed  by  the  fear  that  he  himself  would  have  tubercu- 
losis that  he  was  practicall}'  incapacitated  and  developed  mild 
compulsive  symptoms.  When  he  passed  the  "danger  period"  at  23, 
however,  he  regained  his  confidence  and  shook  off  the  fear  of 
tuberculosis  very  largely. 

He  joined  the  army  in  the  Spring  of  1915  and  remained  in  England 
under  training  for  a  year  and  a  half.  This  was  distinctly  to  his  ad- 
vantage, for  he  gained  more  confidence  in  himself  and  felt  that  he  had 
become  a  competent  individual.  During  this  period  he  had  no  anx- 
iety, and  was  philosophically  resigned  to  whatever  might  happen  in 
France.  He  went  there  in  January,  1917,  and  was  glad  to  find  that 
conditions  were  better  than  he  had  been  led  to  expect.  When  shelled 
for  the  first  time  he  became  worried  rather  than  frightened,  and 
quickly  got  used  to  it  It  was  possible  for  him  to  have  shells  drop 
quite  close  to  him  without  his  being  at  all  frightened.  When  he  had 
been  fighting  for  about  six  weeks  he  caught  cold,  had  a  bad  tracheitis 
and  bronchitis  and  lost  his  voice.  When  coughing,  he  brought  up  blood 
several  times  and  of  course  began  at  once  to  worry  about  tuberculosis. 
With  the  natural  ph3-sical  strain  of  this  infection,  added  to  the  worry, 
he  felt  very  much  dragged  down  and  fatigued  and  continued  so  for  about 
ten  days.  Then  two  5.9  shells  dropped,  one  ten,  the  other  thirteen  feet 
from  him.  The  concussion  did  not  cause  him  to  lose  consciousness, 
but  he  became  so  excited  that  he  could  not  talk  sensibly  and  was  in- 
coherent for  an  hour  at  least.  He  went  to  bed,  but  could  sleep  very  little, 
and  in  the  morning  he  found  himself  horribly  afraid  and  trembling. 
With  great  effort  he  kept  himself  at  work  for  a  few  days,  and  then 
was  fortunate  enough  to  be  sent  away  for  a  course  of  study  for  twelve 
days.  During  this  time  he  recovered  from  his  fatigue,  but  worried 
constantly  about  having  to  return  to  his  batteries  and  could  not  con- 
centrate on  his  study.  He  went  back  to  the  line  apprehensive  of 
what  might  happen.  The  difficulty  of  continuing  in  his  work  became 
cumulatively  greater.  He  was  "jumpy"  during  the  day,  inconstant 
fear  of  the  shells,  but  keyed  himself  up  to  the  task.  At  night  he  was 
always  dreaming  of  being  wounded  in  a  ghastly  fashion,  and  for  some 
time  had  more  fear  of  being  wounded  than  of  being  killed.  Before 
long,  however,  he  reached  the  stage  of  wishing  a  shell  woiild  end  his 
troubles  completel}-  and  began  to  spend  a  good  deal  of  time  alone  in 
planning  some  form  of  suicide  that  would  afterward  seem  to  have 
been  an  accident  For  five  or  six  weeks  the  struggle  continued, 
although  he  felt  more  and  more  that  it  would  be  impossible  for  him  to 
"carry  on  "  indefinitely.  About  this  time  he  was  in  the  open  one  day 
and  a  German  field  gunner  spied  him  and  tried  to  hit  him  with  twenty 
or  thirty  shells.  This  experience  almost  finished  him,  and  he  be- 
cajne  so  upset  that  his  battery  commander  sent  him  to  take  charge  of 


39 

a  wagon  line  in  order  that  he  might  have  less  trying  work.  Although 
in  less  clanger  here,  there  were  other  worries  from  which  he  was  not 
free.  Always  rather  sensitive  to  the  horrors  of  war,  he  now  became 
obsessed  by  them,  and  marveled  continually  that  the  whole  ghastly 
business  could  be  possible.  He  said  later  that  he  thought  it  was  not 
improbable  that  he  may  have  clenched  his  hands  and  shrieked  at  the 
horror  of  anything  so  cruel  existing.  When  awake,  this  was  his 
strongest  feeling.  Another  symptom  also  developed.  This  was  a 
difificulty  in  uttering  guttural  sounds,  which  soon  spread  to  include 
all  phonation,  making  him  stammer  constantly.  When  it  was  later 
suggested  to  him  that  this  may  have  been  connected  psychologically 
with  the  loss  of  his  voice  and  fear  of  tuberculosis,  he  admitted  that 
this  was  probably  the  case,  inasmuch  as  these  fears  were  much  in  his 
mind  at  the  time  the  speech  difficulty  began. 

In  spite  of  these  troubles  he  continued  working  for  about  a  month 
longer,  although  the  effort  must  have  been  great,  considering  that  he 
had  very  little  sleep,  interrupted  by  nightmares,  and  that  during  the 
day  he  was  both  excessively  fatigued  and  obsessed  with  horror. 
Altogether  he  had  struggled  on,  in  spite  of  these  harrowing  symp- 
toms for  three  and  a  half  months!  Finally,  however,  his  superior 
officer  sent  him  to  divisional  headquarters.  There  he  got  so  much 
worse  that  he  had  to  be  sent  almost  immediately  to  a  hospital.  Once 
there,  it  seemed  to  him  that  if  he  were  ever  sent  back  to  the  line  he 
would  go  mad.  He  was  so  depressed  at  the  thought  of  his  failure 
and  the  conviction  that  he  was  a  coward  that  he  frequently  cried. 
The  hospital  he  was  in  for  nearly  a  month  was  next  to  a  parade 
ground  and  at  night  they  practiced  gunnery.  With  his  extreme  sen- 
sitiveness to  sounds  this  terrorized  him.  Then  he  was  removed  to  a 
hospital  in  London,  where  he  improved  quite  rapidly,  so  that  his 
main  symptoms  became  not  so  much  anxiety  with  its  accompaniments 
as  depression  and  an  obsession  with  the  wickedness  and  horror  of 
war.  This  latter  was  developed  to  such  a  point  that  he  was  able  to 
take  absolutely  no  interest  in  such  striking  events  as  the  capture  of 
Messines  Ridge  which  occurred  while  he  was  in  the  London  hospital. 
He  said  that  he  was  able  to  think  of  nothing  but  the  carnage  that  must 
have  taken  place  there.  He  felt,  however,  that  this  attitude  was  dis- 
tinctly abnormal,  in  fact,  that  it  was  one  of  his  difficulties.  Wicked 
and  horrible  as  war  might  be,  he  spontaneously  admitted  that  in  the 
present  situation  one's  duty  was  not  to  think  about  it,  but  to  fight, 
and  end  the  struggle  as  soon  as  possible.  At  the  same  time  he  knew 
that  it  was  his  thinking  about  it  which  incapacitated  him. 

When  he  was  first  put  in  the  hospital,  the  horrible  sights  at  his  last 
station  were  constantly  before  his  eyes,  as  well  as  the  immediate  hos- 
pital surroundings.  This  lasted  only  a  few  days  and  then  it  became 
a  matter  not  of  seeing  but  merely  of  thinking  about  the  bloodshed. 
Finally,  he  reached  in  London  the  point  where  he  was  able  to  drive 
these  thoughts  out  of  his  mind  by  an  effort  of  will,  or  where  he  could 
read  a  little  and  so  distract  his  mind. 


40 

His  dreams  are  of  interest.  In  the  latter  part  of  his  stay  in  the 
line,  and  for  the  first  month  in  hospital,  he  dreamed  constantly  of 
working  with  his  battery  and  being  under  shell  fire,  and  this  dream 
was  consistently  accompanied  with  great  terror.  When  he  began  to 
recover,  he  had,  with  these  previous  stereotyped  dreams,  another 
recurring  one.  He  was  in  the  country  near  his  home,  which 
distantly  resembled  the  country  in  France  where  his  battery  was. 
He  was  under  shell  fire,  which  he  returned,  but  always  with  decreas- 
ing effect,  so  that  his  battery  was  gradually  shelled  out.  In  these 
dreams  he  would  sometimes  leave  the  battery  and  run,  alone.  At 
other  times  he  would  run  with  another  oflBcer.  Occasionally  the 
brigadier  was  with  him,  who  looked  on  and  criticized  during  the 
fighting.  The  brigadier,  however,  always  disappeared  before  he  had 
to  run  from  the  guns.  The  scenery  of  his  home  was  not  the  only 
matter  external  to  war  that  appeared  in  the  setting  of  his  dreams,  for 
he  began  to  replace  his  gunners  with  people  he  would  read  of  during 
the  day.  Finally,  dreams  occurred  that  showed  a  direct  regression  to 
childhood,  and  the  relation  between  the  object  of  fear  in  his  early 
life  and  what  stimulated  that  emotion  in  the  war.  He  began  to 
dream,  not  that  he  was  fighting  against  Germans,  but  that  Indians 
were  his  foes. 

This  case  is  interesting  both  clinically  and  psychologic- 
ally. We  have  an  individual  who  showed  strong  neurotic 
tendencies  before  the  war,  who  adapted  himself  only  briefly 
to  it,  and  then  developed  symptoms  after  his  resistance  was 
reduced  b5^  a  worry  that  originated  in  times  of  peace.  His 
dreams,  too,  showed  a  tendency  to  include  material  outside 
of  war,  and  finallj^  became  a  distortion  of  the  great  fear  of 
his  childhood,  namely,  that  of  Indians.  He  was  constitu- 
tionall}'  afQicted  with  a  disgust  of  bloodshed  and  violence, 
and  this  became  in  his  neurosis  the  most  prominent  factor 
in  disabling  him  from  active  service.  Running  parallel  to 
this  were  certain  clinical  features.  The  symptoms  of  pure 
and  simple  fatigue  were  less  prominent  in  this  case  than  is 
usual,  and  his  disease  was  always  much  more  subjective 
than  objective.  He  had  at  any  time  very  little  nervous 
starting,  and  when  I  examined  him,  six  weeks  after  his 
first  admission  to  a  hospital,  he  showed  no  tendency  to  jump 
when  noises  occurred,  but  was  obviously  greatly  irritated 
by  them.  He  had  a  little  restlessness,  and  stammered 
pretty  constantly  in  his  speech,  although  the  latter  was 
steadily  improving. 


41 

The  next  case,  that  of  a  lieutenant,  ag^ed  20,  illustrates  the 
effect  of  war  on  one  who  had  always  been  considered  rather 
below  par  nervously.  Strictly  speaking,  this  is  not  an 
anxiety  case,  in  fact  all  the  symptoms  he  showed  were 
those  which  are  usually  merely  complications  in  the  anxiety 
neurosis.  It  is  included  here,  however,  as  an  example  of 
the  very  much  poorer  adaptation  made  in  war  time  by  those 
who  are  not  completely  adapted  to  the  demands  of  civil 
life,  at  the  time  they  enter  the  army. 

Case  VI.  As  a  child  he  had  frequent  night  terrors  and  was  afraid 
of  the  dark.  As  he  grew  older  he  was  high  strung  and  could  not  find 
himself  at  an  elevation  without  wanting  to  throw  himself  down.  He 
was  never  horrified  by  seeing  animals  killed  but  took  a  delight  in  it. 
He  was  shy  with  both  sexes.  He  played  games  in  moderation  only, 
because  he  was  never  able  to  run  any  great  distance.  In  fact,  his 
father,  who  was  a  physician,  took  him  from  school  at  the  age  of  15 
on  account  of  his  lack  of  strength,  and  discouraged  him  from  the  idea 
of  studying  medicine  because  he  was  too  nervous.  He  was  always 
subject  to  headaches  which  were  somewhat  improved  by  glasses. 

In  training  his  first  symptom  developed,  which  was  a  sharp  pain 
in  the  left  groin  that  got  better  when  he  lay  down.  This  was  appar- 
ently hysterical,  as  no  physical  reason  could  be  found  for  it.  After 
this  he  began  to  have  shortness  of  breath,  pain  above  the  heart  and 
palpitations,  with  occasional  attacks  of  dizziness.  He  was  absent  on 
sick  leave  for  a  while.  His  superior  officer  did  not  wish  him  to  go  to 
the  front,  but  he  insisted  on  it,  and  was  finally  sent  to  France  in  Sep- 
tember, 1916,  after  he  had  been  seventeen  months  in  training.  He 
found  himself  at  first  somewhat  afraid  of  the  shells,  but  soon  got  used  to 
them.  The  horror  of  the  war,  however,  grew  on  him,  and  he  came  to 
pity  the  Germans  as  much  as  the  British.  His  weakness,  however, 
was  his  main  difficulty,  for  he  had  to  lie  down  half  the  time.  This  he 
regarded  as  failure  and  became  depressed  over  it.  Then  his  com- 
manding officer  committed  suicide,  and  the  idea  of  his  doing  this  also 
obsessed  him  to  such  an  extent  that  he  thought  he  was  going  mad. 
He  drove  a  knife  into  his  upper  lip  and  smashed  a  looking-glass 
because  he  hated  to  see  himself.  An  extra  long  spell  of  duty  in  the 
trenches  made  him  incapable  of  any  further  effort  and  he  was  sent 
home.  In  the  hospital  in  England  his  chief  difficulties  were  depres- 
sion and  thoughts  of  suicide  and  a  desire  to  mutilate  himself.  As  to 
the  latter,  he  at  first  feared  that  he  would  do  himself  serious  harm; 
but  later  he  discovered  that  a  slight  pain  and  the  drawing  of  blood 
gave  him  the  satisfaction  he  seemed  to  crave.  His  chief  trouble  was 
the  lack  of  any  confidence  in  himself.  His  failure,  as  such,  ceased  to 
bother  him,  and  he  rationalized  that  comfortably  with  the  conviction 
that  he  should  never  have  been  sent  to  the  front.     He  complained, 


42 

too,  of  lack  of  memory  and  concfentration.  His  reaction  was  typically 
neurotic  and  offered  more  difficulty  in  the  way  of  treatment  than  the 
usual  war  neurosis.  He  insisted  that  he  was  physically  incapable  of 
outdoor  exercise,  yet  always  complained  of  a  headache  if  he  stayed 
indoors.  He  said  he  wanted  to  go  back  to  the  front,  but  he  knew 
that  he  couldn't,  and  refused  to  consider  the  possibility  of  getting 
well  with  the  idea  of  doing  some  work  at  home.  Therefore,  he 
argued,  there  was  nothing  left  for  him  but  to  think  of  suicide. 

As  he  showed  no  signs  of  organic  heart  trouble  physi- 
cally, one  is  safe  in  assuming  that  these  symptoms  were 
largely,  if  not  entirely,  neurotic,  and  that  the  patient  was 
an  individual  not  quite  capable  of  meeting  the  ordinary 
strain  and  stress  of  civil  life,  consequently  far  from  com- 
petent to  deal  with  the  strain  of  war. 

The  following  case  is  also  not  typical,  but  is  included  here 
to  show  how  what  is  essentially  a  peace  neurosis  may  de- 
velop syinptoms  that  are  colored  by  the  environment  of  war. 

Case  VII.  The  patient  is  a  captain  in  the  French  Army,  attached 
as  a  liaison  officer  to  the  British  staff.  At  the  time  I  saw  him  he  had 
returned  to  duty  and  was  good  enough  to  give  me  a  retrospective 
account  of  his  neurosis. 

He  had  a  severe  attack  of  meningitis  at  3,  and  as  a  result,  was  very 
delicate  as  a  child.  It  was  not  thought  by  his  parents  that  he  ever 
would  be  strong  enough  to  be  educated,  and  he  was  given  no  school- 
ing until  he  had  himself  demonstrated  his  intellectual  ability.  He 
was  always  "nervous"  but  never  had  any  definite  symptoms  and  no 
breakdowns.  He  became  a  barrister  and  passed  successfully  many  ex- 
aminations both  in  France  and  in  England.  It  is  important  to  note  that 
he  had  very  little  anxiety  in  connection  with  any  of  his  examinations. 
He  was  commissioned  immediately  at  the  outbreak  of  the  war,  and 
fought  for  some  months  with  the  French  Army.  Shortly  after  the  begin- 
ning of  the  war  he  got  news  of  the  death  of  his  best  friend.  At  once  he 
began  having  dreams  of  examinations,  in  which  failure  seemed  cer- 
tain, and  he  was  tormented  by  great  fear  of  this.  There  were  other 
dreams  of  his  arguing  in  court  most  ineffectively,  in  fact  so  poorly 
that  his  clients  insulted  him.  He  was  tired  in  the  morning  after  these 
dreams.  Under  this  strain  he  soon  began  to  be  nervous  and  fearful  of 
shells,  but  never  showed  this  fear,  and  in  fact  felt  it  less,  when  he  was 
in  the  company  of  others.  He  had  no  increase  of  horror  at  the  car- 
nage, but  could  never  become  accustomed  to  shell  fire.  After  con- 
tinuing in  this  state  for  eighteen  months,  and,  so  far  as  he  could 
remember,  without  any  particular  aggravation  of  his  difficulties,  he 
fell  in  a  "  fit"  while  drilling  some  men.  He  was  told  that  he  did  not 
have  a  convulsion,  but  talked  as  if  he  were  apologizing  to  the  colonel. 


43 

Following  this,  he  was  extremely  weak  and  had  bad  pains  in  his  legs; 
when  he  walked  it  was  with  a  very  staggering  gait  and  exaggerated 
movements.  He  was,  of  course,  incapable  of  fighting  further,  and 
was  sent  to  the  south  of  France.  He  stayed  there  very  quietly  with 
his  wife  for  nearly  five  months,  for  the  first  two  of  which  he  felt  abso- 
lutely no  affection  for  his  wife.  All  this  time  he  endeavored  to  rest 
completely,  and  did  not  even  read  a  newspaper.  This  was  apparently 
successful  treatment,  for  he  recovered  completely,  and  on  returning 
to  the  front  felt  no  more  fear  and  had  perfect  confidence  in  himself. 
Later  he  obtained  leave  long  enough  to  go  to  London  for  some  Eng- 
lish bar  examinations,  which  he  passed  without  having  any  anxiety 
at  all.  He  continued,  however,  to  repress  his  friend's  death,  trying 
never  to  think  about  it,  and  was  always  disturbed  for  some  time  after 
hearing  the  friend's  name  mentioned. 

Fatigue :  Perhaps  the  most  important  of  all  the  factors 
that  unite  in  the  production  of  an  anxiety  state  is  fatigue. 
So  far  as  I  have  been  able  to  learn,  either  it  or  concussion 
is  present  to  greater  or  less  extent  in  every  case  of  anxiety 
neurosis,  and  it  seems  to  be  possible  to  trace  its  influences 
directly  in  the  production  of  symptoms. 

Although  the  discrimination  may  be  somewhat  academic, 
it  is  possible  to  recognize  two  types  of  fatigue  which  are 
usually  combined.  These  we  might  call  physical  and  men- 
tal in  origin,  although  there  is  probably  no  place  in  medicine 
where  it  is  more  difficult  to  discriminate  between  what  is 
purely  physical  and  purely  mental.  We  may  call  fatigue 
physical  in  origin  that  proceeds  from  physical  factors  out- 
side the  patient,  such  as  continued  exertion  on  duty, 
exposure  to  inclement  weather,  lack  of  food  and  opportu- 
nity to  sleep,  or  physical  disease.  Fatigue  of  mental 
origin  is  that  which  proceeds  from  difficulties  that  are  more 
psychological  than  physical  in  their  operation.  This  in- 
cludes the  constant  stress  of  exposure  to  what  is  extremely 
distasteful,  whether  the  distaste  be  common  to  all  mankind, 
or  an  idiosyncracy  of  the  patient.  It  also  includes  the 
fatigue  coming  from  the  struggle  against  symptoms  already 
in  existence.  These  influences  never  demand  in  times 
of  peace  the  consideration  due  them  in  warfare.  The 
reason  for  this  is  that  escape  from  symptoms  or  from 
environmental  factors  which  are  particularly  trying  is  usu- 
ally possible  to  some  extent  in  civil  life,  but  is  absolutely 
impossible  in  the  trenches. 


44 

Two  cases  of  the  physical  type  may  first  be  quoted: 

C  VSE  VIII.  The  patient  is  a  lieutenant,  aged  29,  who  was  a  regular 
soldier  for  eight  years  before  the  present  war.  He  had  an  extraordi- 
naril}'  normal  mental  make-up,  liked  military  life  extremely,  and  did 
well  in  it,  so  that  he  was  made  a  non-commissioned  officer  almost 
immediately  after  enlistment.  He  went  to  France  as  a  sergeant  with 
the  original  expeditionary  force,  and  went  through  all  the  severe 
fighting  in  the  retreat  from  Mons  and  the  first  battle  of  Ypres, 
unscathed. 

He  exhibited  no  symptoms  whatever  with  his  first  shell  fire,  and  en- 
joyed the  fighting  hugely.  At  the  first,  he  did  not  like  to  "mess  the 
dead  about,"  but  soon  became  quite  indifferent  to  this  part  of  his 
duties.  He  was  several  times  rather  saddened  by  losing  all  his  chums, 
but  he  was  never  unable  to  continue  in  his  duties,  and  soon  forgot 
about  these  incidents.  From  the  standpoint  of  adaptation  he  might 
easily  be  called  a  perfect  soldier,  for  he  was  not  only  completely  de- 
void of  fear,  but  well  disciplined,  and  took  a  keen  enjoyment  in  his 
work  and  was  able  to  continue  fighting  quite  unaffected  by  the  hor- 
rors that  are  trj-ing  to  all  ordinary  individuals.  In  August,  1915,  he 
had  a  slight  touch  of  rheumatism,  not  severe  enough  to  send  him  to 
the  hospital,  but  enough  to  drag  him  down  a  bit.  He  thought  that  he 
had  recovered  completely  from  this.  Two  or  three  months  later  the 
Germans  exploded  a  mine  right  in  front  of  the  trench  in  which  he  was. 
This  is  perhaps  quite  the  most  fearful  event  in  any  soldier's  life,  as  all 
the  ground  is  shaken  and  the  extent  of  the  damage  done  may  be  appall- 
ing. The  patient  went  pale  for  the  first  time  in  his  life,  but  did  not  lose 
his  control,  and  kept  his  men  ' '  standing  to  ' '  immediately.  It  was  a  new 
experience  to  him  and  rather  a  shock.  He  began  to  think  for  the 
first  time  about  danger.  He  was  in  an  area  where  mining  was  the  chief 
form  of  attack,  and  he  would  frequently  hear  the  Germans  digging 
beneath  his  dugout  He  got  too  restless  to  sleep  while  on  active  duty, 
but  could  sleep  well  when  back  in  billets.  This  continued  for  two 
months,  during  which  time,  he  thinks  now,  he  was  probably  getting 
worse  than  he  realized  at  the  time.  He  was  getting  more  and  more 
on  edge,  although  he  felt  no  real  fear,  and  could  always  tell  by  the 
sounds  where  shells  were  going  to  land.  About  six  weeks  after  the 
mining  incident,  he  was  buried  in  a  dugout.  He  did  not  completely 
lose  consciousness,  but  was  so  dazed  that  he  had  to  lie  down  for  a 
couple  of  hours.  Following  this,  he  was  nervous,  had  a  chronic  head- 
ache and  could  not  sleep,  even  in  the  billets.  He  would  lie  for  a  long 
time,  trj-ing  to  get  to  sleep,  his  head  aching,  seeing  dugouts  being 
blown  out,  and  the  men  being  bowled  over,  and  imagining  himself  in 
the  way  of  shells.  Occasionally  he  could  feel  these  things  as  well  as  see 
them,  but  could  always  by  an  effort  of  will  convince  himself  that  they 
were  only  imaginations.  With  these  hallucinations  he  had  no  real  fear, 
but  was  very  much  bothered  and  wished  they  would  go  away.     All  this 


45 

time  he  was  in  a  position  of  the  most  trying  responsibility  which  any 
non-commissioned  officer  can  have,  since  he  was  company  sergeant 
major.  Feeling  this  responsibility,  he  continued  his  work,  but  got 
gradually  worse  and  worse.  His  sleep  became  poorer.  Not  that  he 
had  nightmares,  but  he  found  himself  constantly  awaking  with  a  start 
whenever  he  fell  off  to  sleep.  In  the  daytime  he  was  bothered  by  a 
constant  tendency  to  "jump"  whenever  a  shell  came,  but  was  able  to 
keep  himself  perfectly  calm  as  far  as  any  outsider  could  see.  It  was 
only  with  the  greatest  effort,  however,  that  he  was  able  to  get  through 
each  day.  He  began  taking  morphia,  but  was  able  to  secure  very 
little  sleep  with  it.     He  thought  sometimes  of  suicide. 

After  two  months  of  these  troublesome  symptoms,  his  officers  saw 
that  he  was  not  well  and  sent  him  to  England.  Here  he  picked  tip 
quickly.  He  soon  began  to  sleep  a  little,  but  he  never  was  able  to  get 
more  than  five  hours  sleep  in  any  night.  After  a  rest  of  three 
months  he  applied  for  some  light  duty,  and  was  given  company 
accountant  work.  This  soon  bored  him  extremely,  and,  as  he  insisted 
on  returning  to  France,  he  was  given  a  commission  and  sent  back  to 
the  front  in  January,  1917,  after  he  had  been  nine  months  in  England. 
On  his  return,  he  found  the  fighting  not  very  active,  and  was  able  to 
go  ahead  with  it  very  well  for  a  while,  with  his  condition  about  the 
same  as  in  England;  that  is,  he  felt  rather  high-strung  and  was  able 
to  get  only  four  or  five  hours  sleep  at  night.  In  April  he  was  sent  to 
Arras.  A  month  before  this  he  had  a  dream  that  he  was  going  to  be 
bowled  over  by  a  shell,  buried,  and  wounded  in  the  neck.  He  thought 
a  good  deal  about  this,  and  realized  perfectly  that  he  was  not 
thoroughly  fit.  At  Arras,  where  the  fighting  was  very  heavy,  his 
sleep  got  much  poorer.  He  had,  however,  no  "jumpiness, "  nor  any 
idea  of  suicide.  Then  in  April  he  led  his  men  in  an  advance,  and 
almost  immediately  on  leaving  the  trench  was  bowled  over  and  buried 
by  a  shell  and  at  the  same  time  hit  in  the  neck,  knee,  and  the  hand 
(all  superficial  wounds).  He  was  not  unconscious,  but  dazed  and 
had  to  be  carried  back  to  the  hospital.  There  he  felt  first  rather 
pounded  and  blinded,  but  slept  a  little,  and  was  fairly  comfortable 
after  ten  days.  In  fact,  he  felt  so  much  better  that  he  undertook  a 
journey  down  to  his  base.  This  exhausted  him  and  he  arrived  almost 
in  a  collapse.  He  was  in  camp  at  the  base  for  three  weeks,  during 
which  time  he  tried  to  rest,  and  took  tonics,  but  got  steadily  worse. 
He  became  depressed,  thinking  that  something  was  going  to  happen 
and  kill  him.  It  was  not  exactly  a  shell,  and  he  could  not  tell  what 
it  was  to  be, — it  was  just  a  restless,  vague  anxiety.  He  found  that  he 
could  not  concentrate  his  thoughts  sufficiently  to  read.  Occasionally 
he  contemplated  committing  suicide  in  order  to  finish  up  quickly 
what  was  going  to  happen  anyway.  He  had  practically  no  sleep,  but 
whenever  he  would  doze,  would  wake  with  a  start,  feeling  that  some- 
thing had  hit  him. 

This  was  as  near  as  he  came  to  a  real  nightmare.     He  had  several 


46 

dreams  of  being  taken  prisoner.  This  probably  expressed  an 
unconscious  relief  from  having  to  fight,  but  how  far  this  was  from  his 
conscious  ideals  may  be  gathered  from  what  took  place  on  waking. 
He  would  immediately  imagine  himself  in  the  situation  of  prisoner, 
and  then  in  fancy  start  a  fight  and  escape  back  to  the  British  lines. 

He  was  in  various  hospitals  for  two  weeks,  and  then  was  sent  to  a 
special  hospital  for  nervous  cases  which  was  very  pleasantly  situated 
in  the  country.  Ten  days  in  this  quiet  situation  improved  his  con- 
dition considerably  and  he  began  to  get  some  sleep.  On  a  day  after 
no  sleep,  he  would  have  a  bad  headache,  be  restless  and  apprehensive, 
with  a  feeling  that  he  would  never  get  better,  always  being  worse 
when  he  was  alone.  The  distraction  of  talking  to  others  did  him 
good.  Any  exertion,  however,  would  lead  to  a  very  bad  headache. 
He  thought  that  if  he  were  left  permanently  alone  he  would  go  mad. 
At  no  time  had  he  had  real  nightmares.  It  was  quite  interesting  that 
he  discovered  when  riding  on  a  train  that  he  would  become  terrorized 
on  passing  through  every  tunnel  lest  he  should  be  crushed. 

This  case  shows  how  incapacitating-  pure  fatigue  without 
the  development  of  any  marked  neurotic  symptoms  may  be. 
Judging  from  what  one  gathers  in  taking  the  histories  of 
many  patients,  it  might  be  safe  to  say  that  had  this  lieuten- 
ant's superiors  not  sent  him  back  to  the  hospital  after  his 
final  burial,  he  would  have  developed  a  typical  anxiety 
state,  for  all  the  symptoms  were  potentially  present.  We 
can  probably  account  for  his  long  and  successful  struggle 
against  a  neurosis  by  the  fact  that  he  was  so  extraordinarily 
well  adapted  to  fighting.  But,  as  he  himself  said,  "There 
is  no  man  on  earth  who  can  stick  this  thing  forever." 

The  following  case  is  interesting  and  typical  in  two 
respects.  In  the  first  place,  he  was  a  man  well  adapted  to 
fighting,  whose  first  symptoms  were  those  of  fatigue,  apart 
from  any  neurotic  manifestations.  Secondly,  his  neurosis, 
once  established,  remained  in  abeyance  for  thirteen  months 
while  at  home  only  to  blossom  out  immediately  on  his 
return  to  the  front. 

Case  IX.  The  patient  is  a  lieutenant,  aged  21,  who  showed  no 
distinctly  neurotic  tendencies.  He  was  somewhat  shy  with  girls  and 
slightly  so  with  boys,  but  played  many  games  with  them,  and  seems 
to  have  been  rather  a  normal  child.  His  only  abnormality,  apparently, 
was  a  tendency  to  self-consciousness.  He  enlisted  in  September,  1914, 
and  found  that  the  training  did  him  much  good,  for  he  became  more 
sociable;  it  "made  a  man  of  him,"  as  he  said.     He  went  to  France  in 


47 

February,  1915,  and  although  he  was  at  first  somewhat  frightened, 
soon  got  used  to  being  shelled.  He  enjoyed  the  life  and  was  careless 
of  the  sight  of  wounds  and  death. 

After  fighting  for  seven  months,  he  became  somewhat  fatigued  and 
had  occasional  dreams  of  fighting,  with  fear.  In  the  daytime,  how- 
ever, he  had  only  a  tendency  to  start  when  the  shells  came,  and  no 
consciousness  of  fear  whatever.  He  was  then  invalided  home  with  a 
fever,  and  three  months  later  was  given  a  commission,  spending  nine 
months  in  training.  He  then  returned  to  France  as  an  officer  in  Octo- 
ber, 1916.  Heat  once  joined  a  company  which  had  just  been  in  severe 
action  and  was  feeling  very  shaky.  This  had  some  effect  on  him,  and  he 
found  himself  slightly  nervous  and  a  little  depressed  at  the  thought 
of  going  back  to  the  firing  line.  He  tried  to  persuade  himself  tliat 
he  did  not  care  what  happened.  When  examined  later,  he  told  me 
that  this  initial  fear  was  probably  due  to  the  rough  time  he  had  before 
he  left  the  firing  line  thirteen  months  earlier.  He  had  never,  in  all 
the  time  he  was  at  home,  gained  complete  possession  of  his  confi- 
dence. He  found  now  that  he  could  get  no  enjoyment  in  the  fight- 
ing, and  became  sensitive  to  the  horrors.  He  began  to  take  rum 
in  order  to  keep  fit.  The  fighting  was  so  active  that  he  had  little 
opportunity  to  sleep,  but  when  he  did  have  the  chance  he  was  not 
bothered  by  bad  dreams.  Gradually  he  became  more  and  more  fright- 
ened, but  was  constantly  successful  in  hiding  any  signs  of  it  The 
fatigue  became  so  extreme  that  he  felt  that  it  could  not  last  long,  and 
wished  fervently  that  a  shell  would  come  along  and  finish  him. 

One  night  a  raid  was  on,  and  a  heavy  barrage.  He  remembered 
nothing  more  until  he  awoke  in  a  dressing  station  where  he  was  told 
that  he  had  been  buried.  Apparently  he  had  been  unconscious  for  three 
or  four  hours.  His  head  ached,  as  did  his  back,  where  the  earth  had 
hit  it.  He  had  no  dizziness,  no  further  loss  of  consciousness  and  no  diffi- 
culty in  thinking.  As  there  is  no  evidence  of  concussion,  except  from 
his  amnesia,  it  is  probable  that  it  was  rather  slight.  He  felt  very 
much  frightened,  however,  but  managed  to  get  some  control  of  this  as 
he  was  carried  further  from  the  firing  line  back  to  the  field  ambulance. 
He  remained  here  ten  days,  and  recovered  sufficiently  to  insist  on 
being  sent  back.  He  found  on  his  return  to  the  line,  however,  that 
he  could  not  sleep,  and  was  extremely  frightened  during  the  day. 
He  realized  at  once  that  he  could  not  stick  it  out,  and  after  a  week 
asked  to  be  sent  back.  This  was  done  at  once,  and  he  was  sent  direct 
to  England.  He  was  in  the  hospital  for  a  week  where  his  sleep  was 
very  poor  and  continuously  troubled  by  nightmares,  the  content  of 
which  was  exclusively  a  repetition  of  previous  terrifying  incidents  at 
the  front  He  was  extremely  shaky;  in  fact,  his  legs  moved  so  much 
that  he  crossed  them  in  bed  in  order  to  keep  them  quiet  This  ex- 
treme shakiness  he  ascribed  not  only  to  his  nervous  strain,  but  also  to 
the  injury  to  his  back,  which  remained  sore  for  some  time,  and  which 
he  thought  included  an  injury  to  his  spinal  cord  which  was  responsible 


48 

for  the  movements  of  his  legs.  At  the  end  of  the  week  he  got  up  out 
of  bed  in  order  to  return  to  his  home.  He  then  found  that  he  could  not 
uncross  his  legs,  and  was  so  spastic  that  he  had  great  difficulty  in 
walking.  In  his  home,  his  family  and  friends  exhausted  him  by  their 
constant  efforts  to  distract  his  mind.  He  was  very  restless,  and  his 
dreams  became  more  insistent  at  night.  He  remained  at  home  three 
and  a  half  months,  during  which  time  his  fatigue,  shakiness,  sleep- 
lessness, all  appeared  worse.  His  dreams,  however,  became  less 
severe,  in  that  they  appeared  at  less  frequent  intervals.  He  was  then 
sent  to  a  special  hospital  where  I  saw  him  after  two  months  stay. 
He  had  improved  in  all  directions.  The  dreams  had  ceased.  He 
had  no  chronic  fatigue,  although  he  was  still  rather  easily  fatigable. 
The  shakiness  had  disappeared  except  when  he  was  tired  or  when  he 
tried  to  stand  or  walk  with  his  legs  apart.  His  gait,  however,  was 
improving  very  rapidly  under  the  methods  of  re-education  which 
were  employed. 

He  said  that  he  kept  himself  from  thinking  much  about  returning 
to  France,  but  when  that  idea  did  come  in  his  mind  it  was  always 
accompanied  with  a  fear  that  he  would  be  a  coward  if  he  were  once 
back  in  the  firing  line  again.  He  worried  a  good  deal  about  his  failure, 
because  he  had  seen  a  good  deal  of  prejudice  against  a  man  who 
' '  goes  sick, ' '  whatever  the  cause. 

It  may  probably  be  taken  as  additional  evidence  of  this  patient's 
essential  normality,  that  he  had  no  trouble  whatever  in  abstaining 
from  alcohol  after  leaving  the  line,  although  he  had  been  afraid  that 
he  would  have  difficulty  in  this. 

The  following  two  cases  are  illustrative  of  fatigue 
engendered  by  mental  as  well  as  physical  diflBculties,  and 
difficulties,  too,  that  would  not  be  at  all  incapacitating  in 
times  of  peace  with  as  normal  individuals  as  these  patients 
are. 

Case  X.  The  patient  is  a  major,  aged  35,  who  had  spent  seven  years 
in  the  army  with  the  rank  of  captain,  but  had  resigned  some  five  years 
previous  to  the  beginning  of  the  present  war.  During  this  time  he 
had  been  living  in  North  Africa,  engaged  for  some  years  in  tribal 
warfare,  and  following  that  had  built  a  plantation  miles  from  civili- 
zation where  he  lived  very  happily.  He  is  a  typical  representative  of 
the  British  adventuring,  colonizing  class.  At  the  beginning  of  the 
war  he  returned  to  England  and  was  given  a  commission  as  major, 
and  fought  for  two  years  before  his  breakdown  occurred.  In  make-up 
he  was  apparently  an  unusually  normal  individual,  and  in  many  talks 
with  him  I  could  discover  no  abnormality  except  that  he  was  a  con- 
firmed bachelor,  and  that  he  was  always  unusually  antagonistic  to 
inefficiency  in  any  superior. 

On  going  to  France,  after  a  short  initial  period  of  fear  with  the 


49 

shells,  he  became  fully  adapted  to  the  conditions  and  enjoyed  the 
fighting  hugely.  Probably  as  a  result  of  his  many  years  of  life  in  the 
open,  he  knew  how  to  adapt  himself  to  an  uncivilized  environment, 
and  took  considerable  pride  in  making  not  only  himself,  but  all  his 
men,  unusually  comfortable.  He  fought  continuously  for  one  and 
one-half  years,  with  absolutely  no  symptoms.  At  one  time,  when  he 
was  feeling  particularly  fit,  he  was  in  a  dugout  with  two  other  men  when 
a  heavy,  high  explosive  shell  pierced  the  roof  and  exploded.  All 
three  men  were  laid  out  immediately,  and  all  apparently  paralyzed 
for  half  an  hour.  The  patient  said  he  thought  he  might  have  been 
unconscious  for  a  second  or  two.  It  was  difficult  to  recall  his  sensa- 
tions. He  remembered  being  very  much  frightened,  but  what  occa- 
sioned that  fear  he  can  not  remember.  He  also  was  unable  to  say 
whether  he  was  really  paralyzed  or  unable  to  try  to  move,  or  perhaps 
afraid  to  move.  At  any  rate,  at  the  end  of  the  half  hour  all  three 
men  picked  themselves  up,  laughed  at  each  other  and  went  on  with 
their  work.  The  patient  felt  no  after-effects  whatever.  As  such  an 
incident  is  frequently  given  as  the  occasion  of  a  neurosis,  it  is  impor- 
tant to  note  how  little  effect  it  may  have  on  those  who  have  not  been 
troubled  with  any  symptoms  prior  to  the  event 

After  a  year  and  a  half  of  fighting,  the  patient  was  transferred  to  a 
battalion  that  was  under  the  command  of  a  brigadier  whom  he  felt  to 
be  not  only  very  inefiicient  but  antagonistic  to  him.  They  had  fre- 
quent difference  on  various  matters,  and  finally  when  they  disagreed 
on  tactics,  the  brigadier  had  him  sent  home  on  sick  leave,  although 
he  was  perfectly  well.  He  returned  to  the  front  after  a  few  months' 
stay  at  home,  and  was  very  much  disappointed  to  be  transferred  to 
the  same  division  and  come  under  the  authority  of  his  old  enemy  ten 
months  after  leaving  him. 

Up  to  this  time  he  felt  perfectly  well,  but  the  strain  of  constantly 
following  orders  of  which  he  did  not  approve,  began  to  tell  on  him. 
He  became  sleepless  at  night,  and  "jumpy"  during  the  day.  This 
"  jumpiness  "  at  first  was  not  accompanied  by  fear,  but  later  on  he 
became  fearful  of  the  shells.  Much  irritated  by  this  failure,  he  made 
strong  efforts  to  control  his  emotion,  and  did  succeed  in  hiding  it  from 
his  brother  officers  and  from  his  men.  The  brigadier,  however,  con- 
tinued to  bother  him  in  every  possible  way,  so  the  patient  thought. 
He  was  continually  pestered  for  reports,  so  that  he  had  to  spend  much 
time  in  purely  clerical  work.  He  began  to  dream  of  this.  Night 
after  night  he  would  be  making  endless  inventories  which  he  never 
was  able  to  finish,  so  that  he  would  wake  in  the  morning  more  tired  than 
when  he  had  gone  to  sleep.  Finally  the  patient  and  his  brigadier  came 
to  an  open  quarrel  about  a  case  of  court  martial  when  the  patient  accused 
his  superior  of  attempting  to  coerce  the  court  illegally.  The  brigadier 
over- ruled  him,  but  was  possibly  in  the  wrong  as  he  made  no  com- 
plaint of  the  patient's  actions  to  headquarters.  As  the  patient  had 
begun  to  have  occasional  terrifying  dreams  of  fighting  at  night,  he 


50 

felt  that  his  resistance  was  steadily  decreasing.  He  tried  taking 
bromides  in  ten  grain  doses  every  night  for  some  weeks,  but  finally 
discontinued  the  use  of  this  drug  because  he  found  it  was  failing  to 
give  any  benefit  at  this  dosage.  He  had  been  on  active  service  for 
many  months,  so  felt  justified  in  applying  for  leave.  This  was  granted 
and  he  came  to  London.  There  he  consulted  a  neurologist  who 
advised  him  to  go  to  a  hospital,  which  he  did  at  once.  He  showed 
some  tremulousness,  but  no  other  obvious  abnormality,  and  his  sub- 
jective symptoms  were  not  so  intense  as  is  often  the  case.  His 
nightmares  occurred  regularly  every  night,  only  for  about  a  week, 
after  which  they  became  fewer  in  number,  and  after  two  weeks  dis- 
appeared entirely.  Sleeplessness,  however,  continued  to  bother  him, 
and  sometimes  he  would  lie  awake  practically  the  whole  night 
rehearsing  in  his  mind  the  past  quarrels  with  the  brigadier,  or  imagi- 
nary defiances. 

After  two  or  three  weeks  stay  in  the  hospital  he  began  to  go  out  for 
occasional  walks  or  rides  in  a  motor,  and  he  was  then  disgusted  to  find 
how  easily  he  was  fatigued  and  how  fearful  he  was  of  the  traffic. 
After  a  month  of  hospital  residence  he  went  to  a  convalescent  home  in 
the  country,  from  which  he  wrote  me  a  month  later  to  state  that, 
although  he  had  no  obvious  symptoms,  his  convalescence  was  pro- 
ceeding much  more  slowly  than  he  had  expected.  He  found  himself 
still  nervous  with  any  sudden  noise,  terribly  giddy  if  he  were  in  a 
high  place,  and  much  upset  by  thunder-storms.  In  addition,  he  could 
not  entirely  shake  himself  of  the  obsession  concerning  the  brigadier. 
Unfortunately  there  was  no  opportunity  for  any  psychological  analysis 
of  this  antagonism  to  his  superior,  but  judging  from  the  experience  of 
others  with  such  cases,  it  seems  probable  that  it  would  have  been  a 
comparatively  simple  matter  to  give  this  patient  insight  into  and 
control  over  his  trouble. 

It  is  probabl}^  safe  to  say  in  this  case  that  the  main  factor 
in  this  patient's  breakdown  was  his  constitutional  inability 
to  act  subserviently  and  take  orders  from  one  whom  he  did 
not  respect.  This  spirit  is,  of  course,  an  asset  in  times  of 
peace.  In  military  life,  however,  it  is  a  distinct  dis- 
advantage. 

Case  XI.  The  history  of  this  patient  presents  a  somewhat  similar 
situation  to  that  just  described.  He  was  commissioned  in  the  regular 
army  in  1906,  became  an  officer  in  the  artillery,  and  enjoyed  the  army 
life.  When  the  war  broke  out  he  was  home  on  sick  leave  from  India 
and  joined  the  expeditionary  force  in  France  in  November,  1914.  His 
make-up  showed  that  he  had  not  been  a  completely  normal  individual. 
As  a  child  he  had  many  nightmares  of  falling  and  was  also  afraid  of 
the  dark.  This  latter  fear  never  entirely  left  him,  for  he  stated  to  me 
that  he  thought  he  probably  would  still  be  afraid  to  remain  alone  in  a 


51 

dark  house.  He  showed  no  other  obviously  neurotic  tendencies,  but 
admitted  himself  to  be  given  to  worry,  and  to  being  over-conscientious. 
He  confessed  to  a  distinct  vein  of  pessimism.  He  had,  too,  a  strong 
tendency  to  be  unusually  resentful  when  deceived  or  ill-treated.  As 
an  example,  he  spoke  of  once  being  decoyed  into  buying  some  trash 
at  an  auction  sale.  After  discovering  the  worthlessness  of  the  things 
he  thought  and  dreamed  about  the  deceit  that  had  been  practiced  on 
him  for  some  months.  He  felt  very  resentful  at  the  auctioneer  and 
indulged  in  phantasies  of  revenge.  Both  his  father  and  grandfather 
had  been  soldiers  of  some  eminence,  and  the  ideals  of  military  service 
took  a  large  place  in  his  life.  After  being  commissioned  he  had  fre- 
quent dreams  of  being  in  the  army  without  having  passed  the  necessary 
examinations.  In  these  dreams  he  felt  that  these  examinations  were 
still  to  come,  and  that  he  was  going  to  fail.  On  waking,  this  feeling 
would  persist  for  some  time,  with  considerable  depression. 

On  going  to  France  he  fought  continuously  for  many  months  and 
enjoyed  it  When  first  shelled  he  wanted  to  leave,  but  had  no  other 
abnormal  reactions.  Occasionally  he  would  feel  a  little  timorous 
when  going  into  the  front  line  trenches  for  observation  of  the  effect  of 
his  battery's  work.  This  feeling  was  always  qtiite  brief,  however, 
and  never  incapacitated  him.  After  eight  months  of  fighting  he  was 
one  day  very  heavily  shelled,  after  which  he  was  "jumpy"  and  for 
some  weeks  every  sound  he  heard  meant  a  shell.  He  recovered  from 
this  spontaneously,  however. 

From  May  to  November,  1916,  he  acted  as  liaison  artillery  oflScer 
with  the  flying  corps.  He  enjoyed  this  work  extremely  and  felt  so 
full  of  life  that,  although  it  was  not  at  all  a  part  of  his  duties,  he  used 
to  go  on  bombing  raids  for  the  fun  of  it  He  did  not  enjoy  being  shot 
at  by  the  anti-aircraft  guns,  but  was  never  sufficiently  frightened  to 
develop  any  symptoms  whatever.  After  five  months  of  this  work, 
he  felt  that  he  was  not  doing  all  that  he  might,  and  so  applied  for  a 
position  in  the  artillery  again.  He  was  sent  home  to  raise  and  train  a 
new  siege  battery.  His  troubles  then  began.  None  of  his  officers  or 
men  had  ever  been  in  France,  so  that  he  had  to  instruct  all  of  them 
in  many  essentials.  An  additional  difficulty  was  that  he  was  forced 
by  regulations  to  teach  methods  which  he  had  not  seen  in  use  at  the 
front,  and  which  he  thought  the  men  would  only  have  to  forget  again. 
At  the  end  of  this  period  he  spent  two  weeks  giving  the  battery 
practice — firing  which  he  thought  ought  to  have  been  extended  to 
six  months.  He  worried  morbidly  about  the  insufficiency  of  training 
which  his  men  were  getting,  and  felt  that  he  was  up  against  a  system 
more  powerful  than  himself.  To  add  to  his  difficulties  he  had 
innumerable  administrative  duties  to  attend  to  that  he  found  very 
irksome. 

A  week  before  going  to  France  he  had  a  bad  throat.  His  physician 
kept  him  in  bed  for  two  days,  and  said  that  his  rest  ought  to  be  con- 
tinued for  a  month  as  he  was  worn  out  and  his  heart  was  irregular  in 


52 

action.  He  left  his  bed,  however,  to  go  over  to  France,  feeling  quite 
played  out.  He  spent  ten  days  tuning  up  his  tractors,  etc. ,  and  then 
to  his  intense  disappointment  his  guns  were  taken  from  him,  as  they 
were  urgently  needed  for  another  sector  of  the  line  than  that  to  which 
he  had  been  ordered.  He  and  his  men  were  sent  to  build  gun  posi- 
tions for  another  offensive  that  was  to  take  place  months  later. 
Difficulties  began  once  again.  He  had  not,  or  felt  that  he  had  not, 
enough  men,  material  or  transport  facilities.  Finally,  the  general 
over-ruled  his  judgment  as  to  where  the  emplacements  should  go. 
The  patient  felt  that  a  terrible  mistake  was  being  made,  and  it  became 
an  obsession  to  him.  On  going  to  sleep  at  night  it  was  in  his  mind, 
and  although  he  did  not  dream  of  it,  he  never  slept  more  than  four 
hours  and  found  himself  thinking  at  once  of  the  same  subject  when 
he  awoke.  While  continuing  in  his  work,  he  saw  a  neighboring 
battery  knocked  out  with  German  shells,  and  began  to  live  over  in 
prospect  the  experiences  the  batteries  he  was  building  would  have  in 
the  future. 

Next,  the  Germans  began  to  shell  all  the  roads  back  of  the  British 
lines,  indiscriminately,  which  drove  his  men  into  a  panic.  He 
managed  to  put  some  confidence  in  them  again,  but  only  with  great 
difficulty,  and  he  himself  was  beginning  to  wish  urgently  that  a  shell 
might  hit  him,  so  that  he  might  get  a  wound  which  would  remove 
him  from  duty.  It  is  interesting  that  he  did  not  wish  for  death — the 
only  officer  I  examined  who  did  not  look  for  this  form  of  release.  It 
was  probably  because  he  felt  so  outraged  with  the  "system"  that  he 
harbored  the  less  honorable  wish.  On  the  other  hand,  when  his 
doctor  recommended  a  ten  days  rest,  the  patient  refused,  being  stub- 
bornly determined  to  stick  it  out  He  was  given  thirty  grains  of 
bromide  a  day  which  improved  his  condition,  but  only  for  a  few  days. 
He  had  been  working  under  these  difficulties  for  six  weeks  when  he 
was  given  orders  that  he  considered  impossible  of  completion  in  the 
time  allowed.  This  made  matters  even  worse  and  he  got  so  that  he 
could  not  eat,  nor  concentrate  his  mind  sufficiently  even  for  the 
purpose  of  reading  orders.  He  was  also  trembling  most  of  the  time, 
and  starting  nen^ously  whenever  shells  came,  although  he  felt  no 
fear  of  them,  in  fact  they  had  a  definite,  conscious  attraction  for  him. 
Finally,  he  saw  several  men  injured  and  one  killed  working  on  a  gun 
emplacement  the  location  of  which  he  had  protested  against.  The 
following  day  he  was  ordered  to  undo  all  his  work  and  remove  the 
emplacement  to  another  spot  This  was  more  than  he  could  bear,  so 
he  went  to  the  doctor  again  and  demanded  relief  from  all  responsibil- 
ity. He  was  sent  to  a  hospital,  and  had  been  in  one  hospital  or 
another  for  six  weeks  when  I  saw  him. 

He  experienced  great  relief  in  leaving  the  line,  but  still  had  other 
difficulties  indicative  of  fatigue.  He  was  "jumpy  "  and  felt  that  he 
was  gripping  hard  on  things  in  order  to  keep  control  of  himself.  He 
spoke  in  a  fixed  tone  and  felt  he  was  mentallj'  incompetent     Paralde- 


53 

hyde  gave  him  sleep  for  one  night,  but  left  him  heavy  for  several  days 
following.  When  the  sleeplessness  passed,  itlefthim  feelingwell.  He 
was  in  bed  for  ten  days  altogether.  Then  he  dreamed  several  nights 
in  succession  of  working  on  his  gun  emplacements.  This  upset  him 
once  more,  but  only  temporarily.  His  sleep  finally  became  quite 
normal,  but  he  continued  to  suffer  with  headaches  and  difficulty  in 
concentration.  His  greatest  difficulty  when  I  saw  him  was  depression 
with  a  feeling  of  failure.  He  feared  that  having  broken  down  in  a 
crisis,  his  future  career  as  a  soldier  would  be  prejudiced.  He  con- 
tinued to  harbor  resentment  against  the  superiors  from  whom  he  had 
suffered,  but  spontaneously  developed  more  and  more  insight  into 
the  fact  that  his  own  reaction  had  not  been  perfectly  normal. 

This  case  presents  some  interesting  points  for  specula- 
tion. The  origin  of  his  fatigue  is  plain  enough,  but  we 
have  to  account  for  so  marked  a  degree  of  fatigue  not 
culminating  in  an  anxiety  condition.  Two  possibilities 
must  be  considered.  In  the  first  place,  he  never  desired 
death  as  a  release  from  his  situation,  which  seems  to  be  a 
pretty  constant  forerunner  of  the  anxiety  state.  Secondly, 
his  mental  conflict  remained  quite  conscious  throughout. 
It  is  possible  that  there  was  in  his  case  less  necessity  for  the 
development  of  neurotic  symptoms  in  that  he  had  an  open, 
conscious  antagonism  to  the  military  situation  in  which 
he  was  placed. 

Concussion :  The  role  of  concussion  in  the  production  of 
anxiety  states  has  been  emphasized  by  the  more  organically 
minded  neurologists  with  probably  too  great  an  emphasis. 
On  the  other  hand,  those  who  have  been  working  psycho- 
logically seem  inclined  to  underestimate  its  importance, 
and,  so  far  as  I  know,  neither  school  has  attempted  to 
make  any  discrimination,  in  their  reported  cases,  between 
the  symptoms  which  could  be  directly  accounted  for  on  this 
physical  basis,  and  those  which  were  more  probably  purely 
psychological  in  origin.  In  less  than  a  fourth  of  the  cases 
I  have. seen  could  concussion  be  determined  as  a  prepon- 
derating factor.  Two-thirds  had  no  suggestion  whatever  of 
concussion  in  their  history.  That  it  is  rarely,  if  ever,  the 
sole  factor  is  suggested  by  the  phenomena  not  infrequently 
reported,  that  many  men  are  often  equally  affected  by  the 
same  explosion,  while  only  some  of  them  develop  symptoms. 


54 

It  has  also  been  stated  that  cases  have  occurred  where  a 
shell  has  dropped  among  a  group  of  men  who  were  resting. 
One  who  was  awake  developed  "shell  shock."  Those 
who  were  asleep  showed  no  bad  effects.  Perhaps  the  most 
convincing  argument  of  all  is  that  the  same  man  may  be 
repeatedly  exposed  to  definite  concussion  at  times  when 
his  general  condition  is  perfect,  and  develop  only  the 
most  temporary  symptoms,  whereas  later  in  his  career  as  a 
soldier  when  fatigue  or  beginning  neurotic  symptoms  are 
present,  a  less  violent  concussion  may  precipitate  a  severe 
neurosis. 

By  examining  cases  with  definite  history  of  severe  con- 
cussion one  can  discover  the  symptoms  which  are  the  direct 
outcome  of  the  physical  injury.     These  are  as  follows  : 

There  is  first  unconsciousness  that  may  last  for  hours,  even 
days.  Lumbar  puncture  at  this  time  may,  according  to  the 
reports,  show  blood  in  the  cerebro-spinal  fluid.  That  there 
are  minute  hemorrhages  throughout  the  brain  has  been 
determined  definitely  in  some  cases  which  have  been  killed 
instantly  by  concussion,  and  is  also  suggested  by  the  fact 
that  retinal  hemorrhages  may  frequently  be  observed  oph- 
thalmoscopically.  When  consciousness  is  recovered  it  does 
not  remain  immediately  and  permanently  clear,  as  the 
patient  is  apt  to  go  through  a  period  of  hours  or  days  in 
which  he  is  constantly  drifting  off  into  unconsciousness  or 
sleep.  Sometimes  consciousness  may  be  retained  for  a 
longer  period,  when  the  patient's  attention  is  continuously 
stimulated.  Retention  of  urine  or  incontinence  of  both 
urine  and  faeces  is  common  in  these  stages.  Many  of  the 
patients,  on  becoming  clear,  are  aphasic.  A  period  of 
delirium  then  is  apt  to  ensue,  during  which  the  patient 
imagines  himself  to  be  fighting  again.  This  delirium  is 
distinctly  of  the  occupational  type,  and  so  far  as  I  could 
learn,  is  not  accompanied  by  fear  unless  neurotic  symptoms 
had  been  present  before  the  concussion,  or  the  patient  has 
an  extremely  abnormal  make-up.  The  patient  may  gain 
insight  into  the  unreality  of  his  hallucinations  if  his  atten- 
tion is  forcibly  directed  to  his  environment.  In  fact,  the 
delirium  is  apt  to   disappear  slowly  as  the   patient   gets 


55 

to  do  this  more  and  more  for  himself.  He  is  then  in  a 
condition  of  great  fatigue  and  extremely  poor  mental 
tension,  the  last  being  demonstrated  by  a  difficulty  in 
collecting  his  thoughts,  defective  orientation,  poor  mem- 
ory for  the  remote  past,  and  practically  no  memory  at  all 
for  the  immediate  past.  Generally  there  is  retroactive  am- 
nesia for  the  concussion  itself,  and  for  a  varying  lapse  of 
time  prior  to  the  accident.  All  mental  operations  are  per- 
formed with  great  difficulty,  and  as  a  rule  inaccurately, 
which  can  easily  be  tested  by  demanding  some  simple  cal- 
culations. The  voice  is  peculiar,  being  very  often  pitched 
somewhat  higher  than  is  usual  for  the  patient,  monotonous, 
and  frequently  slow,  words  being  separated  by  a  pause  of 
one  or  two  seconds.  The  patient  begins  with  greater  or 
less  speed,  according  to  the  severity  of  his  injury,  to  recover 
his  memory  of  the  remote  past,  and  also,  strangely  enough, 
is  frequently  able  to  reconstruct  a  good  deal  of  the  period 
which  immediately  preceded  his  injury,  particularly  if 
some  hints  are  given  him.  In  the  milder  cases  the  patient 
feels  as  well  as  he  ever  did,  after  a  few  weeks  rest. 

In  the  more  severe  cases,  some  symptoms  are  apt  to  per- 
sist. For  a  long  time  the  patient  has  poor  mental  tension, 
and  this  is  so  frequently  associated  with  carelessness  and 
with  the  brief  appearance  of  fanciful  ideas,  that  a  suspicion 
of  paresis  is  often  aroused.  Occasionally  the  patient  may 
retain  delusions  for  months  that  originated  in  his  initial 
delirium. 

The  importance  of  knowing  these  symptoms  lies  in  the 
fact  that  their  presence  in  the  clinical  history  (particularly 
the  dipping  of  consciousness  and  poor  mental  tension)  are 
tell-tale  signs  of  genuine  concussion.  They  are  singularly 
absent  in  the  cases  where  mere  burial,  or  some  other  such 
precipitating  cause,  has  suddenly  produced  symptoms.  In 
those  individuals  where  definite  fatigue  or  neurotic  symp- 
toms are  already  present,  even  in  slight  degree,  the  occur- 
rence of  concussion  may  cause  a  very  sudden  accentuation 
in  the  anxiety  picture.  The  following  two  cases  illustrate 
the  effects  of  concussion  on  individuals  previously  normal 
in  their  make-up  and  in  good  health  when  the  accident 
occurred: 


56 

Case  XTI.  The  patient  is  a  Canadian  from  Toronto,  aged  20.  His 
personal  history  shows  an  extremely  normal  make-up.  In  1915  he 
lost  the  phalanges  and  metatarsals  of  his  left  foot  in  a  railway  acci- 
dent. This  injury  prevented  his  acceptance  by  the  Canadian  military 
authorities  for  a  long  time,  but  finally  he  was  commissioned  in  the 
English  Royal  Flying  Corps.  He  spent  nine  months  in  England  in 
training,  which  he  enjoyed  greatly,  and  at  the  end  of  that  time  he 
was  considered  sufficiently  competent  to  be  sent  to  France.  He  made 
several  successful  flights  over  the  lines,  but  after  only  two  weeks  of 
service  he  was  shot  down  and  crashed  to  the  ground  within  his  own 
lines.  He  was  removed  at  once  to  a  British  general  hospital,  where 
twenty  four  hours  later  he  was  noted  as  being  still  unconscious,  with 
black  eyes  and  bruises  on  his  body,  but  no  neurological  signs.  Four 
days  later  he  had  apparently  recovered  consciousness,  and  had  complete 
control  of  his  sphincters.  A  week  later,  it  is  stated  that  his  memory 
was  much  aided  by  questions,  but  that  he  was  still  hazy  about  recent 
events.  He  could  recognize  that  he  was  in  the  hospital,  but  was  not 
sure  which  one  it  was.  A  week  after  this  again,  he  arrived  in  a  Lon- 
don hospital.*  Here  he  refused  to  stay  in  bed  and  was  found,  by  his 
physician,  lying  half  covered,  with  bright  eyes,  and  speaking  in  a 
very  loud  voice.  Several  questions  were  addressed  to  him,  during 
which  time  he  made  no  response,  merely  staring  at  his  examiner  as  he 
moved  around  the  bed.  Finally,  the  patient  shouted:  "  I  want  to  get 
up."  He  was  told  he  could  not  do  so  immediately,  and  then  when 
questioned  as  to  his  orientation,  he  said  that  he  was  in  Rosedale  (a  sub- 
urb of  Toronto).  Asked  where  Rosedale  was,  he  insisted  it  was  a 
part  of  London,  that  it  was  not  far,  that  he  wanted  a  taxicab  to  get 
there.  When  his  physician  told  him  that  he  would  have  to  cross  the 
ocean  in  order  to  get  to  Rosedale,  he  stared,  but  seemed  content.  His 
physician  discovered  a  wound  on  his  right  hip  (it  looked  like  a 
superficial  machine-gun  wound) .  He  asked  the  patient  about  it,  who 
said  he  didn't  knew,  but  thought  it  must  be  the  mark  of  a  hospital  he 
had  been  in  in  France.  He  expected  the  physician  to  know  what  it 
was,  that  it  was  a  secret  mark  meaning  that  he  could  return  to  the 
line  and  fight  whenever  he  wanted  to.  He  also  explained  it  as  a  mark 
indicating  that  he  could  use  the  lavatory  whenever  he  wanted  to. 

He  gave  no  answers  to  several  questions  as  to  personal  data,  and 
then  suddenly  exclaimed:  ' '  I  want  to  go  to  Rosedale, ' '  but  was  easily 
quieted  When  asked  if  he  dreamed,  he  looked  up  with  a  cunning 
expression,  and  then  said:  "I  down  the  Boche,"-"I  ani  a  live 
wire,"  -  "he  never  lives,"  -  "I  kill  him."  He  was  asked  "Every 
time  ?  "  to  which  he  replied:  ' '  I  kill  every  time. ' '  During  the  utter- 
ance of  these  few  phrases  he  became  very  excited. 

The  next  day  he  was  tractable,  but  anxious  to  leave  and  still  asking 
about  Rosedale.  He  wanted  to  leave  at  once.  When  asked  where  he 
was,  he  laughed,  and  said  the  nurse  told  him  he  was  a  long  way  from 

♦  I  am  indebted  to  Captain  Maurice  Nicol,  R.  A.  M.  C,  for  the  use  of  his  notes 
on  the  observations  made  in  this  hospital. 


57 

Rosedale,  and  when  qviestioned  as  to  his  belief  in  this,  said:  "I 
guess  I  have  to  go  in  a  train  and  in  a  ship,"  but  seemed  uncertain. 
Further  conversation  showed  that  he  had  assimilated  considerable 
information  gained  from  the  nurses,  and  that  he  was  much  more  thor- 
oughly in  touch  with  his  environment.  I  saw  him  for  a  few  minutes 
and  told  him  I  would  see  him  again  the  following  day  in  another  hos- 
pital to  which  he  was  to  be  transferred.  The  next  morning  I  found 
him  oriented  for  time  and  able  to  recognize  me  with  difficulty.  He 
was  much  confused  about  the  names  of  the  hospitals,  and  his  recent 
movements.  None  of  the  necessary  data  seemed  ever  to  be  absent  from 
his  mind,  but  to  be  present  in  rather  a  jumble.  He  showed  a  definite 
mental  tension  defect.  He  was  not  aware  of  being  slowed  in  his  men- 
tal processes,  but  admitted  difficulty  in  recalling  some  data.  In  sub- 
tracting seven  from  one  hundred  serially,  he  did  it  very  slowly,  and 
made  several  bad  mistakes,  which  he  did  not  recognize.  In  giving  an 
account  of  the  remote  past,  he  had  difficulty  in  getting  his  facts 
straight,  particularly  in  their  right  relations  to  one  another.  There 
were  a  number  of  discrepancies  into  which  he  had  only  partial  insight. 
His  carelessness  concerning  his  intellectual  defect  was  very  striking, 
reminding  one  of  the  similar  reaction  in  a  paretic.  He  could  recall 
no  dreams  at  all,  but  remembered  his  life  in  France  well  enough  to  be 
sure  tliat  he  had  no  nervous  symptoms.  He  could  give  no  account  of 
any  hypnagogic  hallucinations.  Although  he  was  well  enough  ori- 
ented concerning  his  situation  in  England,  the  idea  of  getting  to 
Canada  was  still  in  his  mind,  but  he  remarked  a  number  of  times  that 
he  must  speak  to  the  head  of  the  hospital  about  it.  Physically  he  ad- 
mitted some  fatigability,  and  complained  of  his  eyesight,  that  things 
got  foggy  if  he  looked  at  them  long.  Nystagmus  was  present  on  look- 
ing to  the  extreme  left.  His  optic  disks  showed  haziness  and  redness 
with  the  margins  obscured.  The  remains  of  one  hemorrhage  were 
seen. 

Two  weeks  later  he  complained  of  waking  early  in  the  morning, 
but  not  of  any  other  difficulties  in  sleeping.  He  said  his  memory  was 
much  better.  He  could  remember  my  name  and  the  name  of  the  hos- 
pital where  he  had  first  seen  me,  and  external  events  that  had  occurred 
on  the  day  of  my  previous  visit.  He  also  said  that  memory  of  his  last 
day  of  fighting  was  coming  back.  He  could  recall  being  chased  by  a 
German  aeroplane,  and  thinking  that  his  observer  had  shot  the  Ger- 
man down.  He  could  also  recall  going  through  various  manoeu- 
vres in  order  to  escape  the  German,  and  said  that  he  suspected  his 
aeroplane  had  been  hit  by  an  anti  aircraft  gun. 

He  was  still  worried  about  going  to  Canada,  this  obsession  now  hav- 
ing taken  the  form  of  fearing  that  a  medical  board  would  send  him 
directly  back  to  France,  that  the  board  would  not  realize  that  he  was 
incompetent  to  fly  again,  whereas  he  knew  that  he  could  not,  because 
he  had  difficulty  in  telling  "up"  from  "down,"  and  was  subject  to 
some  dizziness.     He  also  felt  that  there  was  something  the  matter  with 


58 

his  vision  as  things  did  not  look  perfectly  clear  to  him.  When  tested, 
however,  he  seemed  to  haye  no  defect.  The  nystagmus  on  looking  to 
the  left  was  still  present  and  his  left  pupil  was  slightly  larger  than 
the  right. 

As  the  foregoing  account  shows,  the  patient  developed  no 
neurotic  symptoms  whatever,  following  this  concussion,  his 
difficulties  being  strictly  of  the  organic  type.  There  was 
first  great  confusion  and  disorientation,  with  some  delirium- 
like ideas;  following  this,  considerable  recovery,  as  evi- 
denced by  grosser  intellectual  tests,  but  a  persisting  defect 
for  grasping  more  subtle  situations. 

The  next  case  gives  an  illustration  of  a  less  severe  con- 
cussion, also  without  any  neurotic  reaction.  The  dreams 
he  developed  are  of  particular  interest  inasmuch  as  their 
content  and  the  accompanying  affect  was  distinctly  different 
from  that  of  the  anxiety  state: 

Case  Xlir.  The  patient  is  a  major  in  the  artillery,  aged  39.  He 
fought  during  the  South  African  war  and  had  been  in  the  regular  army 
all  his  adult  life,  There  was  no  trace  of  abnormality  to  be  discovered 
in  his  make-up,  in  fact,  he  had  an  extremely  open,  pleasant  personal- 
ity. He  fought  until  the  end  of  May,  1917,  without  ever  developing 
real  symptoms.  He  was  wounded  three  times,  though  none  of  the 
wounds  were  serious.  Once  after  being  wounded  he  had  a  few  night- 
mares, but  could  not  recall  the  content  of  them. 

At  the  beginning  of  March  he  was  sent  with  his  battery  to  the  Mes- 
sines  region  and  was  extremely  busy  preparing  for  and  assisting  in  the 
final  bombardment.  On  Jiane  3,  after  having  worked  very  hard,  he 
was  tired  and  lay  down  in  his  dugout  to  rest.  Although  feeling  weary, 
he  had  developed  no  symptoms  indicative  of  real  fatigue  and  had  had 
no  bad  dreams  or  "jumpiness. "  He  remembers  that  the  battery  was 
being  bombarded  and  that  he  heard  two  5.9  shells  land  near  the  bat- 
tery. The  last  he  remembers  was  reading  some  ilispatches  and  turning 
them  over  to  his  captain.  His  next  memory  was  of  awakening  in  a  cas- 
ualty clearing  station.  A  shell  had  come  and  pierced  the  roof  of  his 
dugout,  had  killed  three  and  wounded  nine,  and  broken  up  the  bed  on 
■which  he  was  lying.  Some  iron  from  the  bedstead  hit  him  in  the  ab- 
domen. The  shell  fire  was  so  heavy  that  those  in  the  dugout  could 
not  be  rescued  for  some  time.  Then  the  patient  was  dragged  out  into 
a  field.  He  was  partly  conscious,  but  fainted  in  the  field.  When  he 
recovered  from  this  he  insisted  on  going  to  the  battery  and  taking 
charge  of  it.  His  junior  officers  saw  that  he  was  quite  dazed  and  hope- 
lessly incompetent,  but  were  unable  to  get  him  to  leave  his  post  until 
they  told  him  that  the  brigadier  had  ordered  him  to  headquarters. 
He  went  to  headquarters  and  there  became  confused  again,  so  that  he 


59 

was  removed  to  the  casualty  clearing  station.  His  memories  began 
three  or  four  days  after  the  concussion.  The  first  memory  was  of  this 
hospital  being  under  shell  fire,  which  did  not  frighten  him.  For 
about  a  week  he  had  intense  pain  in  his  abdomen,  particularly  on  mic- 
turition, but  that  soon  left  him  entirely.  His  head  ached  and  he  had 
a  big  bruise  on  the  CKxiput,  and  he  suffered  from  intense  photophobia 
and  poor  vision.  There  was  considerable  difficulty  in  talking  as  he 
found  it  hard  to  get  the  right  words.  After  a  week  in  this  hospital  he 
was  transferred  to  London.  There  he  was  slightly  confused  and  dis- 
oriented and  troubled  by  his  dreams  which  recurred  every  night  and 
disturbed  his  sleep.  I  saw  him  a  couple  of  days  after  tliis  when  his 
confusion  had  cleared  up,  objectively  at  least.  He  spoke  in  a  monot- 
onous slow  voice  with  pauses  between  the  phrases  as  if  it  were  an 
effort  to  talk,  and  it  seemed  as  if  he  had  occasional  difficulty  in  find- 
ing the  right  word.  The  pitch  of  his  voice  was  unnaturally  high  and 
had  a  distinct  monotony  that  was  in  marked  contrast  to  his  emotional 
normality.  In  spite  of  the  distress  he  was  in,  he  talked  fully  and 
pleasantly  about  his  experiences.  His  chief  complaints  were  of  pain 
in  the  head,  weakness  and  "shakiness. "  This  last  was  not  objec- 
tively visible,  but  probably  was  his  term  to  describe  his  fatigue.  He 
was  unable  to  give  any  clear  account  of  events  prior  to  his  coming  to 
London,  although  he  could  remember  having  been  in  Boulogne  for, 
perhaps,  two  days.  He  had  become  clear  as  to  his  immediate  environ- 
ment, but  found  difficulty  in  concentrating  his  mind  on  any  topic. 
He  said  he  had  had  visions  of  the  Messines  Ridge  on  going  to  sleep, 
and  he  was  not  quite  sure  whether  he  dreamed  that  he  was  there,  or 
that  he  felt  that  he  was  there  before  actually  going  to  sleep.  There 
was  absolutely  no  anxiety  in  these  dreams,  nor  in  the  daytime,  and  no 
"nervousness"  at  any  time.  There  were  no  neurological  signs,  but 
his  eyes  could  not  be  examined  on  account  of  the  intense  photophobia 
from  which  he  suffered. 

He  told  of  a  recurrent  dream  which  he  had  had  for  a  good  many 
nights,  although  it  had  not  been  present  for  the  last  two  nights.  The 
dream  was  as  follows:  His  guns  were  being  fired  by  creatures  having 
the  bodies  of  frogs  and  the  heads  of  Baimsfather's  caricatures. 
(These  are  cartoons  which  are  extremely  popular  both  in  England 
and  at  the  front  )  These  creatures  did  everything  wrong  and  paid 
no  attention  to  his  orders,  and  he  felt  much  annoyed  by  his  inability 
to  set  things  right.  In  the  first  dream  they  had  the  guns  pointed 
backward  toward  the  British  lines.  In  later  dreams  they  were  turn- 
ing the  treads  from  left  to  right  instead  of  forward.  Finally  the 
creatures  had  the  guns  pointed  toward  the  enemy,  but  did  not  fire 
them,  simply  stood  there.  The  affect  in  all  these  dreams  was  the 
same,  namely,  the  annoyance  at  the  inability  to  get  his  orders  obeyed. 

It  seemed  that  the  men  either  did  not  hear,  or  paid  no  attention. 

A  superficial  analysis  of  this  dream  was  easily  made,  showing  that 
the  details  were  a  jumble  of  ideas  in  his  mind  while  on  duty  at  Mes- 


60 

sines.  Near  his  battery  there  was  a  pool  full  of  frogs.  German  shells 
used  to  drop  in  this  pond,  after  which  frogs  and  slime  would  rain  all 
around  them,  which  was  very  annoying.  The  Bairnsfather  pictures 
he  was  very  fond  of,  and  had  the  walls  of  his  dugout  covered  with 
them.  The  men  not  hearing  them  made  him  think  of  the  frogs  again. 
They  used  to  croak  very  frequently.  One  of  the  sergeants  had  the 
name  of  "Brick,"  and  there  was  a  joke  in  the  battery  that  one  of  the 
frogs  had  called  out  "Brick,  Brick,"  and  the  sergeant  had  answered. 
An  hour  before  the  concussion,  this  sergeant,  of  whom  the  patient 
was  fond,  was  wounded  in  the  ear. 

This  is  a  typical  fatigue  dream,  in  which  the  task  of  the  day  is 
presented  as  something  that  is  annoyingly  impossible  to  complete, 
wherein  the  distortions  from  the  actual  sitiiation  are  the  result  of  other 
annoyances  being  included,  tending  to  make  the  confusion  and  the 
impossibility  of  putting  through  the  work  all  the  greater.  After 
these  recurrent  dreams  he  had  an  isolated  one  that  was  again  a  distor- 
tion of  another  difficulty  at  the  front.  For  the  last  three  weeks  while 
on  duty  he  had  had  trouble  in  getting  up  his  amunition  and  rations. 
In  the  dream  he  discovered  one  of  the  nurses  at  the  hospital  in  which 
he  was  in  London,  trying  to  bring  a  box  of  tea  into  his  room.  She 
was  having  a  hard  time  of  it  and  could  not  succeed.  He  wanted  to 
help  her,  but  could  not  get  to  the  door.  He  felt  that  the  nurse  was 
trying  to  bring  him  rations. 

Nine  days  later  I  saw  him  again,  at  which  time  he  felt  very  much 
better.  His  sight  was  still  poor,  particularly  on  the  left,  so  he  said. 
It  was  difficult  to  believe  that  this  was  a  neurotic  difficulty  for  he 
burned  his  fingers  slightly  in  lighting  a  cigarette.  There  was  little 
ataxia  in  his  movements.  Speech  had  become  quicker,  but  was  still 
high  pitched.  It  was  also  possible  to  detect  an  occasional  defect,  as 
when  he  said  "t"  for  "th,  "  and  sometimes  "d"  for  "1."  His  eye- 
grounds  had  been  examined  and  found  normal,  but  his  visual  fields 
had  not  been  tested  on  account  of  the  photophobia.  He  had  received 
a  letter  from  his  captain  giving  the  details  of  his  accident  and  was 
astounded  to  learn  that  at  least  three  days  were  gone  from  his  memory. 

The  attitude  of  this  patient  toward  the  war  and  fighting  was  in 
marked  contrast  to  that  of  the  anxiety  cases  who  are  either  consciously 
aware  of  their  resistance  to  returning  to  the  front,  or  exhibit  this  re- 
sistance in  their  dreams.  The  patient  was  anxious  to  return  to  duty 
because  he  had  been  promised  the  command  of  a  battery  that  was  to 
be  sent  to  Italy.  As  he  had  never  taken  part  in  any  mountain  opera- 
tions, this  prospect  was  most  attractive  to  him.  His  unconscious 
desire  to  take  up  this  work  is  illustrated  in  the  following  dream,  where 
difficulties  are  surmounted  or  made  ridiculous.  This  dream  occurred 
about  a  week  after  the  last  one  quoted,  and  in  the  interval  he  had 
had  none,  or  remembered  none  on  waking.  The  dream  is  as  follows: 
He  was  training  men  for  Italy  at  Aldershot,  and  decided  to  take  his 
men  to  a  hilly  country  as  that  would  be  more  like  Italy.     He  therefore 


61 

moved  his  battery  to  Devonshire  and  the  men  worked  splendidly,  so 
that  he  was  proud  of  them.  He  made  them  bivouac  out  Ihe  first 
night,  however,  and  they  all  cai:ght  cold  in  their  left  eyes  (the 
patient's  vision  was  poorer  in  the  left  eye).  He  despised  the  men  for 
their  softness,  but  then  realized  that  it  was  partly  his  fault  and  felt  a 
little  ashamed.  Then  the  thought  suddenly  came  to  him  that  they 
would  no  longer  need  to  close  their  left  eyes  when  they  sighted  the 
guns,  and  he  laughed  aloud  at  the  thought  of  it.  He  awoke  laughing. 
That  the  patient  in  this  dream  disposed  of  the  only  symptom  he  was 
aware  of  which  could  prevent  the  assumption  of  his  new  duties,  is  too 
obvious  to  require  further  comment. 

The  following  case  illustrates  another  concussion  in  a  nor- 
mal individual  in  whom  there  had  been  a  short  period  of 
fatigue  prior  to  the  accident,  and  possibly  related  to  that,  a 
brief  development  of  anxiety  symptoms  after  the  accident. 

Case  XIV.  The  patient  is  a  ruggedly  built  officer  about  30,  who 
took  out  his  commission  at  the  beginning  of  1916  and  went  to  France 
at  the  first  of  1917.  Nothing  indicating  any  abnormality  could  be 
discovered  in  his  mental  make-up  during  a  brief  examination.  In 
his  first  exposure  to  shell  fire  he  was  frightened,  but  soon  acquired 
the  ability  of  gauging  the  direction  of  the  shells,  after  which  he  had 
no  fear  whatever.  The  sight  of  bloodshed  gave  him  no  disabling 
symptoms,  but  he  knew  very  well  what  they  were,  as  he  said  he  had 
seen  many  cases  who  had  been  incapacitated  by  horror.  He  fought 
for  several  months  without  any  particular  incident,  and  enjoyed  the 
life.  In  May  he  was,  with  others,  holding  a  salient  for  three  days 
under  terrible  fire.  The  trenches  had  just  been  taken,  both  flanks 
were  exposed  and  the  enemy  was  making  everj'  effort  to  wipe  out 
this  advance  line.  They  had  not  had  time  to  make  any  dugouts 
and  so  there  was  practically  no  protection  from  shells.  On  the  third 
day  only  six  out  of  twenty  officers  were  left  About  11  in  the  morn- 
ing the  patient  was  buried  and  unconscious  for  a  short  time. 

On  recovering  consciousness  he  felt  shaky  and  was  "jumpy,"  but 
carried  on  because  there  were  so  few  officers  left.  His  mind  was  hazy 
and  he  wondered  in  a  dazed  sort  of  a  way  how  long  he  would  be  able 
to  keep  going,  but  was  determined  not  to  give  up.  He  lost  his  abil- 
ity to  gauge  the  direction  of  the  shells,  and  all  the  afternoon  felt  that 
the  Germans  were  aiming  directly  at  him.  This  is  of  course  a  def- 
inite symptom  of  the  anxiety  state,  but  not  one  from  which  recovery 
could  not  have  been  made  if  he  had  been  relieved  from  duty  before 
being  exposed  to  further  strain  or  accident 

About  6  o'clock  that  evening  he  was  buried  again  and  awoke  six  or 
seven  hours  later  in  a  casualty  clearing  station,  with  a  terrible  head- 
ache, and  incoherent.  For  the  next  two  or  three  weeks  he  was  con- 
scious and  unconscious  off  and  on,  and  could  talk  very  little  as  the 


62 

words  seemed  to  stick  in  his  throat.  His  head  ached,  and  he  felt  con- 
fused and  was  dizzy  whenever  he  sat  up  in  bed.  From  the  fourth  to 
the  twelfth  day  he  had  a  fever  that  went  as  high  as  10,5'  and  104''. 
"When  this  left  him,  his  recovery  began  and  went  steadily  forward. 
When  I  saw  him  some  six  weeks  after  the  concussion,  he  was  able  to 
sit  up  and  talk  a  little.  His  speech  was  slow,  in  isolated  phrases,  and 
suggested  a  word-finding  difficulty,  with  occasional  wrong  use  of 
words,  such  as  when  he  said  to  me  as  I  took  my  leave:  "Much 
obliged  to  meet  you, ' '  a  mistake  of  which  he  did  not  seem  to  be  aware. 
Headaches  were  still  present,  coming  on  as  a  rule  about  8  at  night 
and  keeping  him  awake  half  the  night  so  that  in  the  morning  he  would 
feel  very  dull.  Some  nights,  however,  he  had  no  headache  at  all. 
Noises  were  very  unpleasant  to  him  and  he  started  at  every  sudden 
sound,  but  without  any  trace  of  fear.  He  confessed  that  his  memory 
was  still  treacheroiis,  and  was  hazy,  particularly  for  the  period  of  time 
he  had  spent  in  the  hospital  in  France,  and  he  still  had  some  diffi- 
culty in  concentration.  He  said  that  at  first  he  had  slept  very  little, 
and  that  when  he  did  sleep  his  rest  was  disturbed  by  nightmares  of 
being  under  bombardment  in  which  every  shell  was  coming  at  him. 
After  a  month  the  dreams  became  infrequent,  and  when  he  would 
awake  a  realization  of  his  surroundings  always  made  him  perfectly 
comfortable,  and  he  said  that  he  had  never  had  any  fear  whatever 
during  the  day. 

In  this  case  we  have  a  clinical  picture  which  is  almost 
purely  that  of  concussion,  the  only  features  of  an  anxiety 
neurosis  being  the  trouble  a  few  hours  prior  to  the  second 
concussion  when  he  felt  that  the  shells  were  coming  directly 
at  him,  and  nightmares  lasting  for  a  month  or  six  weeks, 
with  similar  content. 

Following  the  concussion,  however,  there  were  no  diurnal 
symptoms  whatever  that  could  not  be  traced  directly  to  the 
concussion.  It  was  interesting  that,  unlike  the  neurotic 
patient,  he  talked  spontaneously  not  at  all  of  himself,  and 
when  personal  questions  were  asked,  replied  to  them  briefly 
and  then  passed  to  some  external  subject. 

The  following  cases  illustrate  the  aggravation  of  anxiety 
symptoms  by  concussion  in  patients  in  whom  the  neurotic 
manifestations  were  already  well  marked: 

Case  XV.  The  patient  is  a  sergeant  of  the  regular  army,  aged  30, 
who  denied  having  any  definite  nervous  trouble  prior  to  the  war.  He 
was  afraid  of  the  dark  as  a  child,  however,  and  had  night  terrors  at 
this  time.  He  has  always  had  a  fear  of  falling,  and  a  slight  feeling 
of  faintness  on  going  down  in  an  elevator  into  the  underground  rail- 


63 

way,  or  would  begin  to  feel  faint  when  in  an  underground  train  for 
any  length  of  time,  a  symptom  which  he  attributed  to  bad  air.  As  a 
small  boy  he  was  not  particularly  mischievous,  but  became  more  one 
of  the  crowd  after  he  had  been  a  few  years  at  school.  He  was  also 
as  a  boy  very  shy  with  girls,  and  recovered  less  from  that  difficulty 
as  he  grew  older  than  he  did  in  respect  to  his  sociability  with  inen. 
He  was  engaged  for  three  years,  and  married  at  21,  and  there  was 
apparently  no  reason  for  this  long  engagement.  He  claimed,  how- 
ever, that  his  married  life  had  been  very  happy.  He  was  eight  years 
in  the  army  before  the  war  began,  and  acted  as  sergeant  practically 
all  the  time,  a  work  which  he  enjoyed  greatly  and  in  which  he  was 
quite  efficient.  He  went  to  France  with  the  first  expeditionary  force 
and  remained  there  for  eleven  months.  For  a  couple  of  days  he  was 
nervous  about  the  shells,  then  got  used  to  them  and  enjoyed  the 
fighting  hugely.  He  was  extremely  expert  with  the  bayonet,  having 
previously  been  an  instructor  in  the  use  of  that  weapon,  and  derived 
considerable  satisfaction  from  his  success  with  it.  After  fighting 
nearly  a  year,  he  became  rather  tired  and  depressed  and  didn't  care 
what  happened  particularly,  but  slept  well  and  had  absolutely  no  fear. 
Then  suddenly  he  was  wounded  at  the  base  of  the  spine  and  through 
the  right  lung  with  machine-gun  bullets.  The  former  was  not 
particularly  serious,  but  the  latter  was,  for  he  lost  a  great  deal  of 
blood  and  had  a  haemothorax  for  many  months.  He  was  invalided 
home  to  England  and  was  a  long  time  in  bed.  During  this  period 
he  felt  fatigued  and  had  many  dreams  at  night  of  fighting.  These 
were  not  dreams  associated  with  fear,  but  more  of  the  fatigue  type,  in 
which  he  was  ceaselessly  fighting  without  relief,  and  would  awake  in 
the  morning  tired  from  his  efforts. 

His  convalescence  was  rather  slow.  For  a  long  time  he  had  diffi- 
culty in  talking  on  account  of  his  weakness  and  shortness  of  breath. 
After  being  in  the  hospital  and  on  leave  for  five  months  he  rejoined 
the  army,  although  he  still  felt  far  from  well.  He  was  put  on  light 
duty,  but  this  included  drilling  where  he  had  to  shout  at  his  men, 
and  he  discovered  that  these  efforts  resulted  in  his  spitting  up 
blood.  This  not  only  alarmed  him,  but  made  him  feel  that  he  was 
being  unwisely  and  unfairly  treated  in  being  placed  on  duty  before 
he  had  completely  recovered.  This  attitude  was  considerably  accent- 
uated by  his  being  ordered  a  month  later  to  return  to  France.  He 
was  sent  to  the  Ypres  section  where  his  trenches  were  five  hundred 
yards  from  the  Germans,  so  that  there  was  no  possibility  for  any  hand 
to  hand  fighting.  He  felt  there  was  little  justice  in  the  system 
that  could  send  an  invalid  into  this  terrible  situation,  and  resentment 
was  strong  within  him.  He  settled  down  into  the  routine,  however, 
and  ceased  to  think  so  much  about  this,  although  he  became  speedily 
very  fatigued  and  fearful  of  the  shells.  These  symptoms  increased 
steadily  and  by  the  end  of  three  months  he  had  got  to  the  point  where 
he  had  very  little  sleep  and  wished  fervently  that  some  shell  would 


64 

take  him  out  of  his  misery.  Then  one  night  he  was  buried  and  was 
under  the  earth  for  three-quarters  of  an  hour.  He  came  to  some 
days  later  with  practically  no  memory  at  all;  in  fact,  all  he  knew  was 
his  own  name.  Consciousness  apparently  was  coming  and  going  for 
some  time,  and  he  was  very  hazy  as  to  his  movements  for  nearly  two 
months.  Although  his  memory  steadily  improved  he  had  difficulty 
in  concentration  for  at  least  six  months.  At  first  he  could  not  speak 
at  all;  then  for  a  month  he  would  whisper,  and  when  he  recovered  his 
voice  he  stammered  for  several  months.  Among  his  first  memories 
were  hallucinations  of  fighting,  with  great  fear,  which  occurred  during 
the  day,  and  of  constant  nightmares,  many  of  them  being  bayoneted  or 
bombarded.  The  fear  in  these  dreams  was  never  of  being  wounded 
but  always  of  being  killed. 

For  many  months  he  got  not  much  more  than  an  hour's  sleep  on 
any  night,  but  after  seven  months  of  hospital  treatment  the  dreams 
became  somewhat  less  frequent  and  his  quota  of  sleep  rose  to  four 
hours  a  night.  Headaches  were  most  troublesome,  being  constant 
for  the  first  month  or  so,  and  after  that  a  frequent  result  of  nightmare, 
as  he  would  awake  from  one  of  his  dreams  in  terror,  and  with 
a  frightful  pain  in  his  head  which  might  last  for  hours.  He  talked 
much  in  his  sleep,  and  on  awaking  his  head  often  felt  very  full,  with 
a  swimming,  giddy  sensation.  During  many  months  he  lay  awake  at 
night  for  hours  together,  thinking  of  the  war  and  imagining  that  he 
was  in  action. 

He  also  had  other,  not  so  usual,  symptoms,  such  as  a  feeling  of  nau- 
sea, difficulty  in  beginning  to  pass  urine,  and  extreme  constipation. 
He  was  subject  to  marked  trembling.  His  head  for  many  months 
shook  almost  constantly  and  he  had  also  marked  tremors  of  the  legs. 
After  he  had  been  in  the  hospital  for  two  months,  an  attempt  was  made 
to  get  him  out  of  bed,  but  his  legs  trembled  so  violently  and  were  so 
weak  that  he  could  not  stand,  and  any  effort  to  make  him  walk  re- 
sulted merely  in  very  exaggerated  movements  of  his  legs.  When  put 
back  in  bed  his  legs  would  shake  so  violently  that  the  bed  trembled. 
When  put  into  a  wheel-chair  his  calf  muscles  were  in  such  constant 
tremor  that  the  whole  chair  shook. 

After  some  months  the  patient  exhibited  few  signs  of  recovery 
under  the  ordinary  treatment  of  rest,  and  it  became  evident  that  there 
was  a  definite  reason  for  this.  He  had  an  unusual  depression.  He 
felt  not  only  that  he  was  not  going  to  get  well,  but  that  he  did  not 
wish  to  recover.  Visits  from  his  wife  made  no  impression  on  him. 
He  had  no  desire  to  see  any  friends  and  did  not  care  whether  they 
were  alive  or  dead.  In  fact,  this  symptom  was  so  strong  that  when 
he  heard  of  the  death  of  his  son,  aged  4  years,  he  had  difficulty  in 
realizing  it,  and  was  not  greatly  impressed.  For  several  months  he 
did  not  care  about  either  the  success  or  failure  of  the  war,  although 
that  was  the  first  interest  to  return.  It  developed  that  the  basis  of 
this  depression  was  his  feeling  of  resentment  at  the  government  and 


65 

the  country  that  had  sent  him  back  to  fight  after  he  had  already  done 
his  dnty;  he  had  suffered  severely  and  was  still  an  invalid,  lie  com- 
plained frequently  of  the  way  in  which  a  "  British  subject  is  treated, " 
mentioning  his  own  experiences  and  his  having  frequently  seen  men 
shot  for  suspected  cowardice.  He  thought  that  they,  too,  were  not 
treated  as  "British  subjects"  should  be.  He  confessed  to  worrying 
about  these  incidents  constantly,  and  that  these  ideas  were  always  in 
his  mind  when  he  returned  to  France  the  second  time.  The  mech- 
anism of  this  depression  apparently  was  that  with  this  resentment 
contact  with  his  fellows  was  broken.  He  had  no  ambition  to  renew 
it,  and  consequently  was  an  isolated  being  for  whom  no  one  cared. 
It  is  typical  of  the  ready  response  to  treatment  which  the  war  neu- 
roses show  that  a  little  personal  attention  and  explanation  as  to  the 
objects  of  examination,  in  which  he  was  led  to  take  some  interest, 
completely  removed  this  depression,  so  that  he  became  bright,  cheer- 
ful and  anxious  to  get  well.  In  the  next  few  days,  during  which  I 
had  an  opportunity  of  seeing  him,  the  recovery  from  many  of  these 
symptoms  was  remarkable.  For  one  thing,  he  got  so  that  he  could 
walk  fairly  well,  and  he  was  perfectly  confident  that  he  would  soon 
be  entirely  recovered. 

Case  XVI.  The  patient  is  a  man  of  4.5,  very  happily  married  for 
twenty  years,  who  had  been  an  efficient  plumber  with  his  own  shop 
for  many  years.  His  make-up  seems  to  have  been  unusually  normal. 
At  the  beginning  of  the  war  he  did  not  enlist  because  he  was  respon- 
sible for  the  maintenance  of  his  family.  When  the  first  Zeppelin 
came  over  London,  however,  he  felt  that  he  could  remain  out  of  the 
war  no  longer  and  joined  up,  although  it  involved  closing  his  busi- 
ness. He  adapted  himself  well  to  the  training,  and  then  went  to 
France,  where  he  acted  as  senior  sapper  for  130  days.  He  enjoyed 
this  work  greatly,  as  he  had  a  good  gang  of  men  under  him  and 
was  able  to  do  most  effective  work.  He  felt  sorry  for  the  wounded 
and  the  killed,  but  it  did  not  upset  him.  Three  weeks  before  the  end 
of  his  stay  in  France  his  working  party  was  spotted,  and  most  of  the 
men  were  killed  with  shells.  Up  to  this  time  he  said  he  had  not  felt 
overworked,  but  after  it  the  war  got  on  his  nen-es.  The  sight  of  the 
dead  horrified  him.  He  felt  as  if  all  the  shells  were  coming  at  him, 
and  was  "jumpy"  at  every  explosion.  His  sleep  was  poor  and  he 
began  to  have  bad  dreams.  He  became  quite  hopeless  of  being  able 
to  continue  indefinitely,  and  wished  that  he  might  be  killed.  For 
three  days  he  had  such  a  headache  that  he  was  not  able  to  hold  his 
head  up  except  when  actively  busy.  Then  a  heavy  high  explosive 
shell  came  and  buried  him.  It  exploded  so  close  that  his  hair  and 
eyebrows  were  burned  off.  He  remembered  nothing  of  it,  but  was 
told  that  he  must  have  fought  his  way  up  through  the  loose  earth 
because  his  head  and  arms  showed  above  ground.  When  the  rescue 
party  dug  him  out  and  brought  him  to  the  hospital,  it  was  found  that 
he  had  such  a  severe  bruise  on  his  buttocks  that  the  doctor  told  him 


66 

he  would  never  walk  again.  This  concussion  took  place  on  July  1, 
1916.  On  July  7,  he  was  taken  to  a  hospital  in  London,  and  his 
memories  begin  again  from  his  stay  in  that  hospital.  He  knows  he 
was  conscious  before  reaching  England  but  can  recall  nothing  of  the 
time.  He  could  not  talk  without  great  effort  in  getting  a  word  "off 
his  chest,"  a  difficulty  which  persisted  for  the  better  part  of  a  year 
when  he  was  at  all  excited.  He  was  at  first  very  deaf,  and  still  is 
hard  of  hearing,  although  this  has  improved  greatly.  (Probably 
middle  ear  trouble. )  He  was  so  weak  that  he  could  not  raise  his 
eyes,  and  was  short  of  breath,  a  symptom  which  was  still  present 
when  I  examined  him  in  June,  1917.  His  legs  were  full  of  pain,  and 
it  was  some  months  before  he  could  walk.  The  pain,  although 
greatly  lessened  in  degree,  persisted  for  a  year.  All  these  symptoms, 
except  the  weakness  in  the  legs,  he  ascribed  to  the  exposure  to  the 
noise  and  gases  of  the  shells,  which  affected  his  eyes,  his  hearing  and 
his  lungs. 

At  first,  in  London,  he  could  not  recognize  his  wife,  and  could 
remember  nothing  about  himself,  but  all  his  memory,  except  for  the 
accident,  came  slowly  back.  Some  forgetfulness  as  to  the  past  was  a 
persistent  symptom.  During  the  daytime  he  was  constantly  '  'jumpy, ' ' 
and  trembling  all  over,  although  he  felt  no  fear.  In  fact,  the  only 
diurnal  fears  he  had  were  when  a  Zeppelin  raid  occurred  and  bombs 
fell  in  the  immediate  neighborhood  of  the  hospital,  or  when  thunder- 
storms occurred.  Also  if  he  were  left  alone  for  a  time,  figures  of 
Germans  would  begin  to  appear  on  the  wall  and  he  would  become 
frightened.  As  he  grew  stronger  and  was  able  to  move  in  a  chair, 
he  would  get  out  of  the  room  and  join  others  when  any  of  these 
visions  occurred.  He  also  suffered  from  hypnagogic  hallucinations 
of  Germans,  sometimes  with,  sometimes  without  fear.  Bad  dreams, 
which  were  worse  than  any  that  he  had  at  the  front,  began  in  the 
hospital.  These,  during  the  following  year,  gradually  decreased,  but 
were  still  occasionally  present  a  year  after  the  concussion.  He  could 
tell  when  they  were  going  to  come  by  a  thumping  in  his  head  before 
going  to  sleep.  The  content  of  these  was  purely  of  fearful  incidents 
in  France.  But  later  he  began  to  dream  of  bombardment  without 
fear. 

He  exhibited  a  splendid  spirit.  He  blamed  no  one,  and  thought 
he  simply  had  had  bad  luck.  When  it  was  suggested  that  he  ought 
perhaps  to  have  been  given  leave,  he  scoffed  at  the  idea,  because  the 
sappers  were  short-handed  at  the  time.  He  was  very  anxious  to  get 
well,  and  seemed  to  be  improving  rapidly  in  spite  of  having  a  high 
blood- pressure. 

Treatment:  The  treatment  of  the  anxiety  states,  al- 
though effective  in  an  astonishingly  large  number  of  cases 
when  intelligently  pursued,  is  nevertheless  not  such  a  simple 
affair  that  the   physician  can  be  guided  by  any  rule  of 


67 

thumb  in  his  procedure.  As  has  been  stated,  the  symptoms 
of  the  neurosis  (no  matter  what  fundamental  physical  fac- 
tors there  may  have  been)  seem  invariably  to  be  determined 
psychologically.  Plainly  then,  the  psychological  effect  of 
every  therapeutic  measure  must  be  considered.  In  this 
report  the  etiological  factors  have  been  given  prominence 
because  it  seems  that  the  treatment  of  the  anxiety  cases 
must  be  individual,  and  must,  in  every  instance,  be  aimed 
at  the  removal  of  the  effect  of  each  cause.  It  can  not  be 
too  strongly  urged  that  consistent  plans  of  treatment  should 
be  followed,  as  would  readily  be  admitted  by  all  who  have 
been  interested  in  the  treatment  of  neurotics  during  times  of 
peace.  There  is,  therefore,  nothing  more  inimical  to  the 
interests  of  the  patient  (or  of  the  army,  in  the  long  run) 
than  a  frequent  transfer  of  these  patients  from  one  hospital 
to  another,  where  different  theories  are  held  as  to  the  cause 
of  the  trouble,  or  where  notes  do  not  accompany  the 
patients,  giving  an  outline  of  what  has  already  been  accom- 
plished or  attempted. 

At  the  outset,  every  patient,  once  a  diagnosis  is  made 
(and  it  should  be  made  speedily),  ought  to  be  removed  as 
quickly  as  possible  to  a  quiet  environment.  It  must  be 
borne  in  mind  constantly  that  a  highly  important  factor  in 
every  case  is  the  conscious  or  unconscious  desire  to  get 
away  from  the  fighting.  Not  unnaturally  then,  symptoms 
tend  to  be  aggravated  by  mere  removal  from  the  line  and 
having  the  patient  placed  under  the  observation  of  a  physi- 
cian, because  the  worse  impression  the  patient  makes,  the 
longer  is  his  absence  from  the  trenches  apt  to  be.  Conse- 
quently, we  obtain  the  history  of  many  patients  of  symp- 
toms becoming  very  much  greater  as  soon  as  they  arrive  in 
a  hospital.  ( Merely  coming  under  observation  is  not  the 
only  reason  for  this  exaggeration  of  symptoms.)  Since 
the  soldier  is  incompetent  to  fight,  he  must  be  in  a  hospital, 
but  once  there,  he  should  be  protected  during  this  period 
from  every  possible  excitement  that  is  liable  to  increase  his 
symptoms.  The  stay  in  any  hospital  which  is  under  shell 
fire,  near  parade  grounds,  or  filled  with  wounded  men, 
should  therefore  be  cut  down  to  the  minimum.     On  the 


68 

other  hand,  if  the  patient  be  taken  too  far  from  the  firing 
line,  if  he  be  sent  over  seas,  for  instance,  he  is  likely  to 
develop  an  idea  of  permanent  absence  from  his  duties  that 
may  stand  in  the  way  of  a  complete  recovery.  Ideally, 
therefore,  we  should  seek  to  place  these  men  in  a  hospital 
quietly  situated  in  the  same  country  where  the  fighting  is 
in  progress. 

The  treatment  at  first  should  be  purely  symptomatic. 
Every  patient  suffers  more  or  less  from  fatigue,  and  it 
is  ridiculous  to  attempt  psychological  treatment  in  one  who 
is  suffering  from  such  a  definitely  physical  disability  as 
fatigue.  The  first  treatment  should  be  to  give  the  patient 
absolute  rest  in  bed  and  produce  sleep  in  as  normal  a  way 
as  possible.  The  Weir  Mitchell  type  of  treatment  is  of 
value  with  some  cases,  but  if  the  patient  is  subject  to  fear 
when  left  alone,  isolation  can  by  no  possibility  lead  to  any 
improvement  in  his  condition.  Some  idea  of  the  individual 
difficulties  must  therefore  be  gained  at  once.  The  question 
of  producing  sleep  is  also  one  concerning  which  no  general 
rule  can  be  laid  down.  Although  there  is  nothing  worse 
for  these  patients  than  the  indiscriminate  and  constant  use 
of  sedatives,  they  may  nevertheless  be  of  great  value  if  prop- 
erly administered.  A  good  method  is  to  give  sufficient 
dosage  of  whatever  drug  seems  to  be  indicated  to  produce 
sleep  the  first  night  when  treatment  is  begun.  The  patient 
should  be  kept  as  quiet  as  possible  during  the  following 
day,  and  an  effort  be  made  to  produce  sleep  the  next  night 
in  a  more  normal  manner,  that  is,  by  the  use  of  baths, 
packs,  etc.  Mild  suggestion  may  be  of  considerable  value 
at  this  stage.  In  practical  experience  the  most  potent 
influence  in  suggestion  seems  to  be  the  general  morale  and 
attitude  of  a  hospital  as  a  whole.  It  is  a  striking  fact  that 
in  those  hospitals  where  reliance  is  placed  chiefly  on  drugs 
there  is  a  constant  difficulty  met  with  in  combating  insom- 
nia, whereas  the  difficulties  are  much  less  in  those  institu- 
tions where  drugs  are  largely  taboo.  If,  on  the  second 
night,  no  sleep  is  obtained  by  hydrotherapeutic  methods  or 
suggestion,  a  milder  dosage  of  a  hypnotic  may  be  effective, 
and  for  this  a  placebo  may  be  later  substituted. 


69 

The  above  statements  refer  to  the  acute  stage  where  gen- 
uine fatigue  is  undoubtedly  present.  It  must  be  borne  in 
mind  that  fatigue,  as  such,  is  a  condition  which  is  readily 
and  rather  speedily  recovered  from  simply  through  rest. 
Consequently  the  period  during  which  the  patient  is  kept 
isolated  and  no  demands  are  made  for  him  to  exert  himself 
in  the  slightest  degree,  should  be  kept  as  brief  as  possible. 
If  this  is  not  done,  a  condition  of  invalidism  is  fostered. 
Just  how  long  this  period  should  be  is  a  matter  which  must 
be  settled  individually,  but  as  a  general  rule  one  might 
say  that  the  patient  should  not  be  left  without  any  demands 
being  made  for  cooperation  on  his  part  in  the  treatment  for 
longer  than  one  or  two  weeks.  This  is,  however,  rather  a 
guess,  inasmuch  as  I  have  not  had  an  opportunity  of  see- 
ing many  of  these  cases  immediately  after  they  have  been 
in  the  trenches.  It  is  of  course  obvious  that  when  concus- 
sion of  any  severity  has  occurred,  a  very  much  longer 
period  of  rest  is  indicated,  as  we  know  even  from  civilian 
experience  that  nothing  is  more  inimical  to  the  welfare  of 
one  suffering  from  physical  injury  to  the  brain  than  fatigue. 
Complete  and  prolonged  rest  for  these  cases  is  therefore 
obligatory.  At  present  we  have  no  drugs  that  combat 
fatigue  of  the  central  nervous  system  directly.  If  further 
study  of  these  cases  reveals  the  chemical  nature  of  this 
disease,  we  might  hope  to  find  some  antidote  for  it  that 
would  materially  reduce  the  period  of  rest  required.  Fur- 
ther than  that,  we  might  even  hope  that  the  same  remedy 
would  prevent  the  steady  increase  of  the  accumulative 
effects  of  the  fatigue  that  we  see  in  the  trenches,  and  thus 
prevent  many  neuroses  from  developing  beyond  the  initial 
stages,  where  fatigue  dominates  the  clinical  picture. 

Proceeding  along  the  lines  of  symptomatic  treatment,  the 
next  stage  should  be  to  combat  the  patient's  most  obvious 
subjective  difficulties,  namely,  the  fear  of  war  and  the 
obsessions  with  thought  of  its  horrors.  These  can  best  be 
met  acutely  by  distraction  in  one  form  or  another.  The 
patient  should  be  given  a  common  sense  talk  and  assured 
of  two  things:  The  first  is  that  he  is  going  to  get  well, 
since  he  has  been  removed  temporarily  from  the  influences 


70 

which  caused  his  breakdown,  and  that  this  recovery  will 
be  greatly  facilitated  by  his  active  cooperation.  The 
second  is  that  he  is  now  under  medical  control  and  that  he 
need  have  no  fear  of  being  ordered  to  do  anything  that 
will  not  be  to  the  advantage  of  his  health,  that  there  is  no 
possibility  of  his  being  sent  back  to  the  line  until  he  is 
completely  well,  but  that,  on  the  other  hand,  because  his 
disease  is  curable,  he  will,  of  course,  have  to  return  eventu- 
ally. In  other  words,  an  effort  must  be  made  to  produce  a 
state  of  mind  wherein  he  is  willing  to  forget  the  war,  for  the 
time  being,  without  fostering  the  idea  that  he  is  out  of  it 
for  good.  It  is  not  enough  for  the  patient  merely  to  be 
willing  to  forget.  Active  efforts  must  be  made  to  distract 
his  mind.  His  environment  should  therefore  be  made  as 
nearly  that  of  civilian  life  as  is  possible  and  practicable. 
This  does  not  mean  that  uniforms  should  be  abandoned. 
The  men  are  still  in  the  army,  and  should  not  be  given  such 
a  suggestion  as  to  leaving  the  service.  Rigorous  military 
discipline,  however,  should  be  relaxed,  and  the  artificial 
social  distinctions  between  different  ranks  reduced  to  a 
minimum.  A  medical  man,  for  instance,  who  can  not 
forget  that  he  has  the  rank  of  major,  is  bound  to  make  a 
pitiful  failure  in  his  efforts  to  treat  a  subaltern. 

Occupation  of  some  kind  should  invariably  be  given,  but 
never  according  to  any  hard  and  fast  rules.  A  game  of  cards 
may  be  all  the  man  can  stand  at  first,  perhaps  it  will  be 
only  a  very  small  amount  of  light  reading.  He  can  progress 
from  this  to  the  less  violent  out-of-door  games,  and  as  his 
strength  increases,  be  given  something  more  productive. 
For  this  reason,  well  equipped  workshops  are  invaluable, 
particularly  for  privates  and  non-commissioned  officers.  A 
course  of  study  is  sometimes  of  considerable  value  for  an 
officer  whose  interests  are  naturally  in  an  intellectual  field. 
The  objects  of  these  occupations  are  two-fold,  being  first, 
to  distract  the  man's  mind  from  the  worries  that  had  so 
much  to  do  in  the  establishment  of  his  neurosis,  and  secondly, 
to  give  him  that  confidence  in  himself  which  is  often  pain- 
fully lacking,  and  which  can  be  re-established  only  by  the 
patient's    actually  achieving  something.     The  prescribing 


71 

of  occupations  should  alwa\'s  be  directly  under  the  control 
of  the  physician  in  charge  of  the  case,  whose  duty  it  is  to 
note  the  exact  effect  which  the  occupation  has  on  the 
patient,  and  to  var\'  its  nature  or  aim  accordingly.  Much 
harm  is  frequently  done  by  advising  some  exertion  which 
fatigues  him  unduh',  and  convinces  him  that  he  has  some 
terrible  weakness.  The  consequent  discouragement  may  be 
extreme,  and  for  a  long  time  stand  in  the  way  of  any 
improvement.  Every  patient  should  therefore  be  examined 
with  great  frequency,  particularly  at  the  beginning  of  any 
occupation  treatment.  The  granting  of  leave  from  the 
hospital  for  a  few  hours,  or  for  a  week-end,  if  judiciously 
used,  may  help  a  patient  considerably.  He  is  thrown  on 
his  own  resources  to  a  greater  extent  than  when  in  the 
hospital  environment,  and  consequently  he  has  a  much 
greater  feeling  of  achievement  and  greater  pleasure  from 
this  than  from  any  intramural  entertainment.  As  practi- 
cally all  those  who  suffer  from  anxiety  neuroses  are  impotent, 
at  least  in  the  acuter  stages,  sexual  indiscretions  do  not 
need  to  be  borne  in  mind,  when  leave  is  granted,  so  con- 
stantly as  tiiey  do  when  the  patients  are  suffering  from  other 
forms  of  disabilit\'.  In  fact,  feminine  companionship  is  an 
excellent  form  of  distraction  to  the  soldier  who  has  been  for 
many  months  in  a  purely  military  environment. 

The  treatment  so  far  outlined  is  essentially  environmental, 
and  aims  at  combating  the  symptoms  in  a  superficial  way. 
In  most  cases  it  will  be  successful  in  removing  all  or  most 
of  the  obvious  symptoms.  There  remains,  however,  the 
fundamental  difficulty  which  has  so  much  to  do  with  the 
development  of  the  neurosis,  namely,  the  antagonism  to  the 
duties  forced  on  the  soldier,  and  often  to  war  in  general. 
These  can  be  eradicated  oyily  by  the  patient  gaining  some 
psychological  understanding  of  the  origin  and  nature  of  his 
symptoms.  Occasionalh"  one  meets  with  an  officer  who  is 
sufficiently  intelligent  to  understand  the  situation  without 
any  outside  help,  and  who  is  capable  of  taking  himself  in 
hand  and  combating  these  tendencies  alone.  This,  how- 
ever, is  rare. 

On  the  other  hand,  those  who  have  experienced  the  great 


72 

difficulties  to  be  met  with  in  civilian  practice,  in  getting 
patients  to  understand  themselves,  will  be  delighted  with 
the  ease  with  which  the  sufferers  from  war  neuroses  are 
capable  of  grasping  the  psychology  of  their  disease  and 
making  use  of  their  knowledge.  This  is,  of  course,  not 
unnatural,  considering  that  we  deal  here  with  men  who  are, 
relatively  speaking,  quite  normal,  and  with  situations  that 
are  essentially  simple.  In  a  few  talks  a  patient  can  be  led 
to  see  how  the  war  sublimation,  which  has  been  outlined, 
has  broken  down,  and  how  it  was  that  he  therefore  developed 
the  tendency  to  think  of  himself  rather  than  of  the  needs  of 
the  army  and  of  the  country,  and  so  became  a  prey  to  fear 
and  horror. 

When  once  the  patient  sees  that  his  disinclination  to 
return  to  the  front  is  essentially  a  selfish  desire  to  avoid  his 
responsibility  as  a  citizen,  he  is  in  a  position  to  decide  quite 
consciously  whether  he  wishes  to  be  a  slacker  or  to  assume 
his  share  of  the  country's  burden.  If  he  has  the  right  stuff 
in  him,  he  becomes  ashamed  of  his  symptoms  and  begins  to 
control  them  quite  speedily.  He  is  soon  eager  to  take  some 
part  in  the  struggle,  and  if  he  is  given  light  duty  which 
does  not  make  too  great  a  demand  on  his  capacity,  this 
capacity  grows,  and  with  it  a  desire  to  return  to  the  field  of 
active  operations  appears.  Probably  nothing  is  gained  by 
an  attempt  to  send  a  man  back  to  the  firing  line  who  does 
not  spontaneously  wish  to  be  there.  Each  patient  has 
learned  that  the  development  of  certain  symptoms  will  cause 
his  removal  from  the  trenches,  and  if  he  consciously  desires 
to  be  out  of  them  he  will  make  little  effort  to  combat  their 
redevelopment. 

Even  when  this  type  of  analysis  is  attempted,  reliance 
should  not  be  placed  on  it  alone.  It  can  not  be  too  con- 
stantly borne  in  mind  that  one  of  the  greatest  difficulties 
from  which  these  neurotics  suffer  is  a  lack  of  complete 
rapport  with  their  fellows.  Many  of  them  feel  (with  some 
justice)  that  they  have  been  ill-treated,  and  a  feeling  of 
responsibility  toward  the  State  is  difficult  to  foster  in  an 
individual  who  feels  that  the  State  has  no  regard  for  him. 
For  this  reason  a  demonstration  of  personal  interest  in  the 


patient  maybe  of  g^eat  value  (Case  XV  is  an  example  of 
this).  The  physician  must  therefore  learn  to  have  a  keen 
sympathy  for  the  patient  as  an  individual,  but  never  to 
have  any  sympathy  whatever  for  the  patient's  symptoms  as 
such.  This  is  not  an  easy  attitude  to  acquire,  and  is 
probably  the  reason  why  few  physicians  who  are  not  trained 
psychiatrists  are  successful  in  treating-  the  war  neuroses. 

As  has  been  said  before,  there  is  a  tendency  present, 
particularly  among-  those  having-  had  a  definite  neurotic 
history  before  the  war,  of  developing  neurotic  troubles  of 
the  civilian  type  when  convalescence  from  an  anxiety  state 
is  achieved.  It  is  not  within  the  provinces  of  this  report  to 
enter  into  the  treatment  of  these  complicating  neuroses, 
inasmuch  as  they  are  essentially  peace  disturbances.  In  so 
far,  however,  as  they  are  determined  by  unconscious  resist- 
ance to  active  service,  they  are  amenable  to  treatment  in  a 
greater  degree  than  are  similar  neuroses  of  civilian  life,  for 
this  is,  psychologically  speaking,  a  simpler  situation  than 
that  which,  as  a  rule,  precipitates  a  neurosis  in  a  civilian. 

Conversion  Hysterias. 

The  conversion  hysterias  do  not  require  so  protracted  a 
discussion  as  it  has  seemed  wise  to  devote  to  the  anxiety 
cases.  Although  in  absolute  numbers  they  are  more  frequent 
in  occurrence  than  pure  anxiety  states,  yet  they  are  so 
much  simpler  in  mechanism  that  it  is  less  di"f£cultto  under- 
stand them  and  to  treat  them.  Moreover,  much  of  what  has 
already  been  said  as  to  fatigue  and  dissatisfaction  with  active 
service  may  be  applied  directly  in  discussing  the  conversion 
hysterias,  provided  one  remembers  that,  although  these  fac- 
tors operate  in  the  two  conditions  alike,  their  development 
is  much  less  extensive  in  the  cases  of  conversion  hysteria. 

These  may  be  defined  as  neuroses  in  which  there  is  an 
alteration  or  dissociation  of  consciousness  regarding  some 
physical  function .  The  term  * '  Conversion  Hysteria' '  is  used, 
because  an  idea  is  transferred  over  into  a  physical  symptom. 
The  cases  are  confined  almost  entirely  to  privates  and  non- 
commissioned officers,  the  reason  for  which  will  be  discussed 


74 

later.  The  purely  hysterical  manifestations  are  apt  to  be 
accompanied  by  mild  anxiet3^  symptoms;  occasionally  the 
latter  are  severe. 

The  symptomatology  is  extremely  varied,  although  there 
have  been  no  s3'raptoms  described  in  the  war  cases,  so  far 
as  I  know,  which  have  not  been  well  known  in  times  of 
peace.  Even  a  brief  study  convinces  one  that  the  more 
important  and  frequent  s3'mptoms  are  those  which  obviously 
provide  the  patient  with  a  relief  from  active  service.  Mut- 
ism is  the  commonest,  apparently.  Aphonia  as  a  prelimi- 
nary symptom  is  rarer,  but  it  often  develops  as  a  stage  of 
recovery  from  mutism,  as  does  stammering.  Deafness  is 
fairly  frequent.  After  the  speech  group,  motor  disturbances 
are  the  most  important.  These  include  monoplegias  and 
paraplegias  or  pareses;  tics,  spasms  and  contractures  are  not 
unusual.  Tremors  are  usually  a  complication  of  an  anx- 
iet3^  state,  and  it  is  quite  frequent  to  find  gait  disturbances 
such  as  have  been  described  in  connection  with  the  anx- 
ieties. It  is  quite  frequent  to  find  an  initial  and  not  very 
severe  anxiety  state  in  a  private  develop  into  a  gait  disturb- 
ance that  is  unaccompanied  by  any  emotional  trouble. 
Spasticity  of  the  legs  is  also  a  rare  symptom,  except  as  a 
complication  or  result  of  an  anxiety  state.  Hyperesthesias 
may  occur  alone.  Parsesthesia  and  anaesthesia  usually 
accompany  hysterical  sj^mptoms.  Blindness  and  amblyopia 
are  not  very  common.  Disorders  of  smell  and  taste  are  still 
rarer. 

Clinical  Course:  What  has  been  said  as  to  the  make-up 
in  connection  with  the  anxiety  states  applies  also  to  the 
hysterical  group,  but  with  the  latter  complete  normality 
seems  to  be  more  frequent.  The  adaptation  to  training  may 
or  may  not  be  good;  naturally  those  who  adapt  themselves 
well  are  less  likely  to  develop  symptoms.  Fatigue  is,  as  a 
rule,  the  first s^^mptom  that  can  be  discovered,  butitis  almost 
never  so  severe  as  in  the  anxiety  cases.  Its  sj-mptoms  are 
therefore  not  so  well  marked.  There  is  little  sleeplessness, 
and  rarely  nightmares,  in  the  purely  hysterical  case.  More 
frequently  one  gets  a  history  of  purely  diurnal  dissatisfaction. 
As  a  rule,  there  is  fear,  with  much  less  "jumpiness"  than 


75 

is  met  with  among-  officers.  There  is  almost  always  some 
weariness  and  a  distinct  antagonism  to  the  fighting.  The 
patient  is  rarely  subjected  to  the  mental  conflicts  that  are  so 
distinctive  of  the  prodromal  anxiety  state  in  officers,  because 
the  men  who  develop  hysterical  symptoms  are  privates  whose 
ideals  are  not  so  high,  and  who  do  not  have  to  make  de- 
cisions for  themselves.  Their  responsibilities  begin  and  end 
with  obedience  to  orders.  And  it  is  the  duty  of  the  officers 
to  put  courage  into  them,  not  for  them  to  develop  and  main- 
tain it  themselves.  Not  unnaturally  then,  we  find  these 
men  seeking  to  gain  release  from  the  situation  they  dislike 
in  a  way  which  is  incompatible  with  the  higher  standards 
of  the  officers.  They  look  for  some  valid  excuse  from  the 
firing  line,  and  so,  almost  universally,  hope  to  be  wounded 
in  some  way  that  will  incapacitate  them  from  active  serv- 
ice. I  have  found  either  this  wish  for  a  "  blighty  one,"  or 
else  thoughts  of  some  physical  disease  in  the  history  of 
every  hysterical  case,  except  one,  that  I  had  an  opportunity 
of  examining.  The  exceptional  patient  did  not  seem  suffi- 
ciently intelligent  to  give  an  accurate  histor3^  Occasionally 
the  antagonism  to  fighting  is  the  direct  outcome  of  physical 
accident  or  disease  which  removes  the  soldier  from  the 
trenches.  The  wish  that  develops  is  then  that  he  may  not 
have  to  return. 

This  attitude  of  antagonism  with  some  idea  of  release 
constitutes  the  background  of  the  hysteria.  Then  some- 
thing happens  which  is  the  occasion  for  the  development  of 
definite  symptoms.  A  frequent  cause  is  concussion  which 
may  or  may  not  be  severe.  Case  XV,  the  sergeant  who  was 
exhausted  and  had  been  worried  about  his  inability  to  shout 
without  spitting  up  blood,  and  therefore  had  his  attention 
directed  to  his  voice,  is  an  example  in  point.  After  his  con- 
cussion and  return  to  consciousness  he  was  mute,  following 
that,  aphonic,  and  then  stammered.  A  not  infrequent 
symptom  is  auEesthesia  at  the  area  of  some  slight  injury 
which  is  received  at  the  time  of  concussion.  Not  unnat- 
urally burial  without  concussion  is  a  highly  frequent 
precipitating  factor.  It  is  not  improbable  that  the  over- 
strung soldier  imagines  that  he  is  about  to  be  killed  when 


76 

the  shell  explodes  close  to  him,  and  this  emotional  shock 
upsets  his  mind  sufficiently  to  cause  that  disturbance  of  con- 
sciousness which  we  term  h^^steria.  As  with  the  anxiety 
cases,  the  infliction  of  an  actual  wound  does  not  at  the  time 
precipitate  hj^sterical  symptoms,  but  these  very  often  develop 
later  when  the  private  who  does  not  wish  to  fight  is  conva- 
lescing ph5'sically  from  his  wound.  The  subjective  symp- 
toms are  apt  to  be  continued  indefinitely  in  a  h3"sterical  way, 
that  is,  the  pain  or  disability  may  not  be  recovered  from, 
although  there  may  be  complete  healing-  at  the  sight  of  in- 
jur3'.  Monoplegias  or  spasticities  are  common  symptoms 
with  this  etiology.  Torticollis  may  also  occur  in  this  way. 
It  is  not  difficult  to  reconstruct  the  original  histor^^  of  these 
cases.  There  is,  while  a  soldier  is  still  in  the  trenches,  the 
usual  wish  to  be  awa}''  from  the  distasteful  employment. 
This  wish  reaches  its  fulfilment  when  a  disabling  wound  is 
received,  a  situation  which  is  quite  satisfactory  so  long  as 
the  injury  continues  to  be  disabling.  Once  recovery  sets  in, 
however,  the  prospect  of  returning  to  the  trenches  is  plainly 
before  the  eyes  of  the  soldier.  Under  these  circumstances, 
while  he  is  both  consciously  and  unconsciousl}^  loth  to  leave 
the  comfortable  position  in  which  he  finds  himself,  he  nat- 
urally pays  considerable  attention  to  the  pain  or  disability 
that  is  a  direct  outcome  of  his  wound.  This  attention, 
backed  by  his  wish  for  the  symptoms  to  be  permanent,  con- 
vinces him  that  there  is  no  improvement  in  any  respect  that 
is  to  him  subjectively  obvious.  Consequently  his  conscious- 
ness gradually  adapts  itself  to  the  disability  until  it  is 
incapable  of  conceiving  the  idea  of  true  recovery.  The 
patient,  therefore,  whose  head  has  been  bandaged  over  to 
one  side  with  a  wound  in  the  neck,  continues  to  hold  his 
head  in  that  position  in  spite  of  the  fact  that  there  is  no  real 
contracture  of  scar  tissue.  Similarly  the  man  whose  arm 
may  have  been  put  up  in  a  sling  finds  when  the  sling  is  re- 
moved that  all  power  is  gone  from  the  arm,  or  the  limb  which 
has  been  held  in  a  certain  position  to  avoid  pain  on  move- 
ment is  retained  spastically  in  that  position.  Apart  from 
the  presence  of  these  objective  symptoms,  he  may  be  in  a 
normal  mental  state.     He  is  usually  untroubled  by  any  anx- 


77 

iety,  is  not  easily  fatigued,  and  his  behavior  is  that  of  any 
wounded  man,  that  is  to  say  it  is  quite  normal. 

As  long  as  war  is  in  progress  and  return  to  the  front  is 
imminent  the  patient  prefers  (unconsciously  at  least)  to 
retain  his  disability  rather  than  to  face  the  perils  and 
discomforts  of  trench  life.  Consequently  these  symptoms, 
when  not  treated  persist  as  a  rule  indefinitely.  Occasionally 
through  some  accident  the  patient  discovers  that  the 
function,  which  he  thought  he  had  lost,  is  still  present. 
This  usually  occurs  under  the  stimulus  of  some  sudden 
emotion.  It  is,  of  course,  one  thing  for  an  outsider  to 
observe  a  man  using  a  paralyzed  arm  and  another  thing  for 
the  patient  himself  to  be  aware  of  it.  This  is  only  to  be 
expected  when  we  consider  that  one  of  the  most  fundamen- 
tal characteristics  of  an  hysterical  symptom  is  that  con- 
sciousness, and  therefore  awareness,  as  to  the  function  in 
question  is  lost.  The  patients  who  recover  spontaneously, 
therefore,  by  making  such  observations  themselves  are  rare. 
On  the  other  hand,  owing  probably  to  the  simplicity  of  the 
mental  mechanisms  involved,  treatment  is  as  a  rule  a  very 
simple  matter  and  frequently  successful  in  a  dramatic  and 
permanent  way.  Once  the  disability  has  been  recovered 
from,  the  patient  is  in  a  much  more  normal  state  than  is  a 
man  suffering  from  anxiety  whose  obvious  symptoms  have 
disappeared. 

The  diagnosis  of  these  conversion  hysterias  is  not  so  simple 
a  matter  as  that  of  the  anxiety  states.  Any  competent 
neurologist  should  of  course  be  able  by  the  usual  methods 
to  make  speedy  and  accurate  discrimination  between 
organic  and  functional  loss.  When  the  two  are  combined, 
however,  the  problem  becomes  somewhat  more  difficult. 
Hysterical  anaesthesia,  for  instance,  may  occur  with,  but 
have  a  wider  distribution  than,  that  of  a  pure  nerve  injury. 
The  latter  may  be  overlapped  by  the  former  and  lead  the 
physician  to  believe  that  he  is  dealing  with  a  purely  hysteri- 
cal condition.  A  final  diagnosis  may  therefore  be  made, 
only  after  treatment  instituted  on  purely  functional  lines 
has  been  successful,  and  has  reduced  the  disability  to  its 
legitimately  organic  distribution.     Quite  the  most  difficult 


78 

problem,  however,  is  to  differentiate  a  conversion  hysteria 
from  malingering.  As  I  have  had  little  opportunity  to  see 
cases  of  malingering  as  they  are  presented  at  the  front,  I 
am  unable  to  say  much  on  this  topic  that  is  not  second- 
hand. Some  workers  rely  largely  on  the  suggestibility  of 
the  hysterical  patient  as  a  diagnostic  criterion.  Occasion- 
ally one  meets  with  a  physician  who  goes  so  far  as  to  state 
that  no  patient  who  is  not  hypnotizable  has  a  true  hysteria, 
and  therefore  must  be  malingering.  As  the  individual 
capacity  to  hypnotize  varies  greatly  from  man  to  man  this 
is  probably  a  rather  unsafe  rule.  Again,  if  one  relies  on 
the  impression  which  the  personality  of  the  patient  makes 
on  the  physician  error  is  apt  to  be  frequent.  The  true 
malingerer  is  frequently,  if  not  always,  a  psychopath. 
Again  it  may  require  a  rather  exhaustive  study  to  determine 
whether  the  symptoms  are  produced  on  the  basis  of  a  con- 
scious or  an  unconscious  wish,  which  is  essentially  the 
difference  in  etiology  between  malingering  and  hysteria. 
Probably  the  safer  guide  is  the  history  of  onset.  One 
should  inquire,  therefore,  as  to  the  mental  attitude  of  the 
patient  before  the  onset  of  the  symptoms.  In  a  true  hysteri- 
cal case  an  admission  is  apt  to  be  made  as  to  the  breaking 
down  of  adaptation  to  warfare  and  the  consequent  wish  to 
be  rid  of  it  all,  particularly  the  wish  for  an  incapacitating 
wound.  The  malingerer  is  not  apt  to  reveal  the  history 
because  the  symptom  represents  this  wish  to  him  quite  con- 
sciously. The  hysteric,  on  the  other  hand,  because  there 
has  been  an  unconscious  motivation,  does  not  see  the  con- 
nection between  his  previous  desire  to  be  incapacitated  and 
the  symptom  his  malady  presents.  He  is,  therefore,  more 
apt  to  be  frank  in  the  matter.  In  another  respect  the  his- 
tory may  be  of  importance,  I  imagine.  In  all  the  cases, 
which  I  have  had  an  opportunity  of  examining,  whose 
symptoms  arose  while  in  the  trenches,  there  was  a  history 
either  of  concussion  or  of  a  definite  precipitating  cause,  the 
immediate  result  of  which  was  some  disturbance  of  con- 
sciousness, no  matter  how  slight.  Frequently  it  amounted 
to  no  more  than  the  patient  being  dazed  for  a  few  minutes 
and  finding  himself  with  the  hysterical  symptom,  when  he 


79' 

became  quite  clear  again.  As  the  opinion  of  the  physician 
on  this  matter  when  delivered  to  a  court  martial  may  mean 
life  or  death  for  the  soldier  I  would  prefer  to  leave  this  last 
diagnostic  criterion  as  a  suggestion  until  such  time  as 
further  experience  may  show  whether  the  phenomenon  in 
question  is  universal  or  not. 

The  prognosis  in  these  cases  depends  on  a  number  of 
factors.  An  important  one  is  naturally  the  mental  make- 
up of  the  patient.  An  individual  who  has  a  definite  psy- 
choneurotic make  up  is  prone  to  develop  symptoms,  to  cling 
to  them  more  tenaciously,  and  to  develop  new  ones  if  his 
original  cause  for  removal  from  the  firing  line  is  done  away 
with.  The  more  normal  soldiers,  as  has  been  stated,  are 
apt  to  keep  their  symptoms  indefinitely  until  appropriate 
treatment  is  instituted.  Once  cured,  they  are  delighted 
with  the  result  and  rarely  suffer  a  relapse.  Inappropriate 
treatment,  however,  is  so  ineffective  that  the  opinion  has 
grown  up  that  it  is  useless  to  try  to  get  these  men  back  to 
the  trenches.  The  experience  gained  in  the  better  hospitals 
which  are  devoted  to  the  care  of  the  neuroses  speaks  dis- 
tinctly against  this,  as  they  have  sent  a  large  proportion  of 
their  patients  back  to  France,  only  a  few  of  whom  have 
relapsed. 

Various  types  of  treatment  are  in  common  use.  The  one 
which  appeals  most  to  the  physician,  who  has  a  military 
mind,  is  discipline;  and  this  is  logical  enough  if  the  assump- 
tion be  made  that  the  symptoms  are  really  under  conscious 
control.  If  fear  of  punishment  is  greater  than  fear  of  the 
life  in  active  service,  the  symptoms  will  naturally  tend  to 
disappear.  On  the  other  hand,  the  well-disciplined  soldier 
has  the  habit  of  obeying  developed  to  such  an  extent  that 
he  is  highly  suggestible  to  commands  from  those  of  super- 
ior rank.  These  two  factors  apparently  account  for  the 
cures  which  result  from  this  method  of  treatment.  They 
are,  however,  few  in  number  and  not  apt  to  be  permanent. 
This  can  be  easily  explained  psychologically  if  one  bears 
in  mind  what  has  previously  been  reiterated  as  to  the 
adaptation  of  the  soldier.  An  all-essential  factor  in  this 
adaptation    is   the   feeling   of  unity  with  his  group  which 


80 

the  individual  develops.  Undue  coercion — in  fact  any 
treatment  which  the  patient  may  regard  as  unfair — is  apt 
to  weaken  the  bonds  between  the  soldier  and  the  army 
rather  than  to  strengthen  them;  consequently  although  the 
symptoms  may  temporarily  disappear,  the  wish  for  escape 
from  military  life  is  apt  to  be  even  stronger  than  it  was  be- 
fore, so  that  a  still  firmer  foundation  for  neurotic  symptoms 
is  built  up.  The  application  of  electricity  in  various  forms 
and  of  massage  is  highly  popular  and  more  often  success- 
ful than  disciplinary  treatment.  Its  results,  however,  are 
dependent  purely  upon  suggestion,  and  therefore  open  to 
the  criticisms  which  shall  immediately  be  made  of  this 
method. 

Naturally  enough  conversion  hysterias  arise  on  a  back- 
ground of  extreme  suggestibility.  It  is  not  surprising, 
therefore,  that  any  form  of  suggestion — particularly  hypno- 
tism— is  extraordinarily  effective  in  the  removal  of  the 
immediate  symptoms.  Moreover  it  does  not  serve  to  alien- 
ate the  soldier  from  the  causes  for  which  he  has  been 
fighting.  On  the  other  hand  it  has  a  grave  defect  psycho- 
logically in  that  it  is  aimed  at  the  removal  of  symptoms 
rather  than  causes.  To  the  uneducated  soldier  the  sj^mptom 
has  come  from  nowhere  and,  if  it  is  removed  by  the  sug- 
gestion of  electricity  or  the  more  direct  suggestion  of 
hypnosis,  it  leaves  him  through  the  agency  of  a  miracle — 
consequently  his  mind  is  strongly  imbued  with  the  idea  that 
such  things  can  happen,  with  the  not  unnatural  result  that 
they  do  happen  again.  What  should  be  aimed  at  is  much 
more  the  training  of  the  patient  to  control  the  workings  of 
his  mind,  steadily  combating  the  idea  that  there  is  anything 
miraculous  or  lawless  about  the  functions  of  his  body  which 
have  gone  wrong.  What  is  essentially  re-education  is, 
therefore,  without  any  question  the  best  method  of  treatment 
for  the  conversion  hysterias.  Those  who  are  most  success- 
ful in  gaining  permanent  results  begin  as  a  rule  with  an 
introductory  talk,  when  they  explain  to  the  patient  the 
nature  of  the  disease  from  which  he  suffers.  They  impress 
upon  his  mind  the  fact  that  his  legs,  for  instance,  are  not 
really  paralyzed  but  that  he  has  simply  forgotten  how  to 


81 

use  them  and  that  he  must  learn  to  do  so  over  again.  An 
effort  is  made  to  make  the  soldier  understand  that  this 
process  is  perfectly  natural  and  that  it  will  be  quickly  suc- 
cessful provided  he  makes  the  necessary  effort.  The  next 
stage  is  to  demonstrate  that  the  function  which  is  lost  or 
disturbed  is  really  not  vitally  affected.  At  this  point  sug- 
gestion or  hypnotism  may  be  of  great  value,  provided  that 
the  patient  be  given  immediately  and  convincingly  the  ex- 
planation that  he  has  done  these  things  rather  than  that  the 
physician  has  accomplished  them.  Many  of  those  whose 
treatment  is  most  successful  prefer  to  rely  on  some  sort  of 
trick  in  demonstrating  the  presence  of  the  capacity  which 
seems  to  be  gone.  It  would  be  impossible  to  enumerate  all 
these — in  fact  it  is  probably  best  to  leave  the  choice  of 
method  to  the  natural  ingenuity  of  the  one  who  is  responsi- 
ble for  the  treatment.  A  few  examples,  however,  may  be 
given.  One  has  already  been  cited  in  Case  II,  in  which  the 
patient  who  was  deaf  and  dumb,  was  made  to  see  in  a 
mirror  that  he  jumped  when  a  sudden  sound  occurred 
behind  his  back.  Patients  who  are  mute  or  aphonic  may 
be  shown  that  all  the  movements  of  the  lips,  tongue  and 
glottis  which  are  necessary  to  produce  speech  have  not  been 
lost.  The  patient,  for  instance,  may  be  able  to  whistle,  to 
put  his  tongue  in  required  positions,  or  to  cough.  In  order 
to  make  the  patient  breathe  evenly  Captain  McDowell  has 
introduced  the  method  of  inducing  the  patient  to  inhale  a 
cigarette,  the  smoke  from  which,  if  forcibly  or  irregularly 
expelled,  is  apt  to  be  irritating  and  may  produce  a  cough. 
Coughing  of  course  involves  the  use  of  the  vocal  chords  and 
produces  a  voiced  sound.  Any  patient  who  can  cough  can 
also  say  "  ah  "  and  the  training  may  begin  from  this  point. 
That  power  is  not  lost  from  limbs  may  be  demonstrated  by 
the  presence  of  reflexes,  or  of  contractions  elicited  by  elec- 
trical stimulation  or  by  sudden  movements  that  are  made  to 
prevent  falling,  etc.  A  means  which  is  frequently  effective 
is  to  induce  passive  movements  while  the  operator  actually 
does  less  and  less  in  the  way  of  movement  until  after  a  few 
trials  the  patient  makes  the  motions  without  any  aid  from 
the  operator  at  all.     Where  a  swimming  tank  is  available  a 


82 

demonstration  of  the  ability  to  use  the  legs  perfectly  can  be 
readily  made  in  those  patients  who  suffer  from  difficulties  in 
walking.  Apparently  no  matter  how  severe  any  gait  dis- 
turbance may  be  there  seems  to  be  no  interference  with  the 
function  of  the  legs  in  swimming.  Once  it  has  been  dem- 
onstrated that  any  function  is  not  totally  absent,  it  is  the 
responsibility  of  the  physician  to  see  that  constant  practice 
is  made  and  to  insist  on  a  steady  increase  in  the  extent  and 
number  of  movements  that  are  executed.  When  this  treat- 
ment is  patiently  carried  out  improvement  is  apt  to  be  rapid 
and  the  results  permanent.  The  reason  for  the  latter  is 
that  the  patient  has  learned  two  things  :  first,  that  his  symp- 
tom originated  mainly  in  a  lack  of  control,  and  secondly, 
that  he  has  found  a  method  of  controlling  symptoms  when 
they  do  arise  or  tend  to  develop. 

Many  of  these  patients,  of  course,  have  personal  diffi- 
culties which  operate  in  connection  with  the  simple  motiva- 
tion, that  has  been  discussed,  in  the  production  of,  or 
maintenance  of,  symptoms.  Many  soldiers  realize  vaguely 
that  their  symptoms,  although  obvious  in  a  physical  way, 
are  really  mental  in  origin.  The  result  of  this  is  to  produce 
in  the  uneducated  man  a  belief  that  he  is  going  insane. 
This  is  naturally  a  fear  which  he  is  apt  to  keep  to  himself, 
and  one  which  is  bound  to  increase  his  worry  and  therefore 
make  his  symptoms  worse  or  more  permanent  unless  he  can 
have  the  situation  carefully  explained  to  him  and  this  redic- 
ulous  fancy  dispelled.  It  is  therefore  of  first  importance 
for  the  physician  to  establish  friendly  relationship  with  the 
patient  and  to  encourage  him  to  bring  his  troubles  to  the 
consulting  room  for  discussion  and  advice.  Improvement 
when  some  quite  simple  personal  problem  has  been  cleared 
up  is  sometimes  so  rapid  as  to  be  startling.  In  connection 
with  this  individual  treatment  one  factor  must  not  be  lost 
sight  of :  the  majority  of  the  men  who  are  now  fighting 
in  all  the  armies  in  Europe  are  essentially  civilians.  For 
the  greater  part  of  their  lives  therefore  they  have  been 
accustomed  to  natural  and  friendly  social  contacts.  In  the 
army  the  demands  of  discipline  necessitate  much  more 
artificiality,  particularly  in  the  relationship  between  officers 


83 

and  men.  As  a  result  the  private  soldier  is  very  apt  to  feel 
a  need  for  friendly  advice  such  as  he  was  able  to  receive  in 
times  of  peace  from  his  physician,  employer  or  clergyman. 
Not  unnaturally  a  feeling  of  isolation  may  grow  up  during 
his  military  life  which  operates  to  increase  his  dissatisfac- 
tion with  the  employment  that  is  forced  upon  him.  The 
private  soldier  is  therefore  extraordinarily  affected  for  the 
better  when  any  sympathy  is  shown  him  by  a  superior 
officer  such  as  his  physician  is.  Any  hospital  in  which  a 
minimum  of  stress  is  laid  on  military  artificialities  is  incom- 
parably more  successful  in  the  treatment  of  these  cases  than 
is  one  where  military  discipline  is  rigidly  enforced,  and,  it 
may  be  added,  a  wise  laxity  in  this  regard  tends  to  increase 
the  respect  which  the  private  soldier  feels  for  his  superiors 
rather  than  to  diminish  it. 

Any  physician  who  has  a  reasonable  fund  of  common 
sense  and  a  natural  interest  in  his  patients  is  bound  to  be 
successful  in  the  treatment  of  many  of  these  cases.  On 
the  other  hand,  as  has  been  said  before,  great  care  must  be 
taken  not  to  confuse  sympathy  for  the  patient  with  that 
sympathy  for  the  patient's  suffering  which  fosters  a  hypo- 
chondriacal tendency.  For  this  reason  the  man  who  can 
best  treat  the  war  neuroses  is  he  who  has  had  years  of 
experience  in  handling  neurotic  patients  and  has  learned  to 
be  sympathetic  with  the  sufferer  as  an  individual  and  yet  to 
be  impatient  with  the  symptoms  as  such. 

After  these  general  statements  as  to  the  causation,  symp- 
tomatology and  treatment  of  the  conversion  hysterias  it  may 
be  well  to  quote  a  few  illustrative  cases. 

Case  XVII.  The  patient  is  a  lieutenant  in  the  Royal  Flying  Corps, 
aged  23.  His  clinical  history  gives  an  excellent  example  of  final 
symptoms  representing  a  regression  to  a  previous  disability,  which 
had  occasioned  him  some  worry.  In  make-up  he  was  apparently  an 
unusually  normal  individual  who  had  at  no  time  shown  any  neurotic 
tendencies  and  had  a  frank  and  open  personality.  He  had  supported 
himself  from  the  age  of  14,  at  which  time  his  father  died,  had 
been  successful  in  business,  and  had  in  addition  found  time  to 
develop  into  quite  an  athlete,  as  well  as  to  become  socially  popular 
with  both  sexes.  He  entered  the  army  in  the  first  year  of  the  war, 
took  well  to  his  training  and  enjoyed  the  fighting  keenly.  For  over 
a  year  he  was  in  the  infantry.     About  a  year  before  the  onset  of  his 


84 

symptoms  he  was  caught  suddenly  in  a  gas  attack  from  which  he 
suffered  severely.  He  was  in  bed  for  some  days  and  then,  although 
he  recovered  rather  quickly  in  other  respects,  had  a  severe  tracheitis 
and  laryngitis  that  persisted  for  weeks.  Not  unnaturally  he  was  able 
to  do  no  more  than  whisper  for  some  time.  As  it  happened,  this 
disability  was  a  considerable  blow  to  the  patient  because  he  had 
always  taken  a  considerable  interest  in  his  voice.  He  had  been  a  good 
singer  and  was  very  proud  of  his  ability  to  make  his  voice  carry  on 
the  parade  ground  for  a  much  greater  distance  than  could  his  brother 
officers.  When  his  voice  returned  he  was  much  worried  to  find  that 
any  effort  to  shout  caused  it  to  become  worse,  after  which  his  voice 
would  be  quite  weak  for  some  hours  or  days.  On  the  first  occasion 
when  he  was  granted  leave  he  went  to  London  and  consulted  a 
laryngologist,  who  unfortunately  told  him  that  he  would  never  be 
able  to  sing  again.  This  was  a  distinct  blow  and  he  worried  about  it 
considerably,  although  this  worry  never  was  severe  enough  to 
incapacitate  him  as  a  soldier  in  the  slightest  degree.  He  continued 
to  enjoy  the  life  extremely. 

As  he  was  obviously  fitted  for  that  type  of  work  he  was  transferred 
from  the  infantry'  to  the  Royal  Flying  Corps  and  soon  became  an 
expert  airman.  In  the  Spring  of  1917  he  one  day  went  over  the 
enemies'  lines  and  made  the  necessary  observations  so  quickly  as  to 
avoid  attack.  While  returning  he  was  shot  at  by  the  anti-aircraft 
guns.  The  shrapnel,  so  far  as  he  was  aware,  although  bursting 
thickly  around  him,  did  not  hit  him  or  his  machine,  but  he  considered 
it  advisable  to  return  to  his  own  lines.  As  a  matter  of  fact  one  of  the 
wings  of  his  machine  had  been  hit  and  consequently  weakened.  The 
sudden  strain  thrown  on  this  wing  when  he  was  landing  caused  it  to 
break,  so  that  he  crashed  to  the  ground.  Careful  inquiry  failed  to 
reveal  any  history  of  his  feeling  at  all  upset  or  nervous  prior  to  the 
instant  of  this  accident.  As  a  matter  of  fact  he  was  elated  over  his 
success.  After  striking  the  ground  he  was  unconscious  for  three 
hours.  When  he  came  to.  he  saw  his  servant  in  the  distance  and 
tried  to  attract  his  attention.  Whether  he  attempted  to  shout  and 
found  his  voice  too  weak  or  not  he  was  unable  to  remember,  as  his 
memory  was  never  entirely  clear  for  the  first  few  minutes  after 
recovering  consciousness.  At  any  rate,  it  was  some  time  before  the 
servant  came  to  him  and  when  he  did  he  found  the  patient  unable  to 
speak.  It  seems  reasonable  to  suppose  that  with  the  concussion  he 
received  and  the  consequent  mental  confusion  his  mind  harked  back 
to  the  only  physical  trouble  which  he  had  ever  known,  namely,  the 
disturbance  of  his  voice  that  had  worried  him  so  much.  He  may 
have  lived  over  in  this  brief  period  of  confusion  the  previous  accident 
when  he  was  gassed.  At  any  rate,  he  seems  to  have  automatically 
begun  to  protect  his  voice  as  he  had  trained  himself  to  do  for  the 
last  year.  This  time,  however,  the  effort  of  protection  was  so 
extreme  as  to  be  pathological  and  resulted  in  total  disuse  of  his  voice. 


85 

The  concussion  from  which  he  suffered  seems  to  have  been  mild  in 
degree,  for  after  a  couple  of  days'  rest  he  felt  quite  well  physically. 
For  two  weeks  he  was  in  a  hospital  in  France  and  then,  as  there  was 
no  improvement  in  his  mutism,  he  was  sent  to  England,  where  I  saw 
him  three  weeks  after  the  accident.  In  this  hospital  efforts  were  at 
once  made  to  make  him  talk,  and  these  speedily  were  successful 
in  so  far  as  he  learned  to  whisper  a  few  words.  He  was  soon  able  to 
whisper  anything  that  he  wished  to  say,  although  it  seemed  always 
to  require  a  greater  mental  than  physical  effort.  By  maldng  him 
cough  and  then  say  "ah"  he  gained  the  use  of  the  voiced  sounds. 
Another  symptom  then  developed,  namely,  that  of  stammering.  It 
seemed  as  if  he  could  bring  himself  to  say  not  more  than  one  or  two 
words  with  one  breath.  By  training  him  to  say  two,  three,  four  and 
then  five  letters  of  the  alphabet  in  one  expiration  he  was  able  to 
make  considerable  improvement  in  this.  Finally,  under  mild 
hypnosis  that  was  practically  nothing  more  than  distraction,  normal 
speech  was  attained  that  produced  an  even,  uninterrupted  repetition 
of  the  alphabet.  He  was  forced  to  apply  this  smoothness  in  utterance 
to  his  ordinary  conversation  at  once,  and  did  not  relapse.  The  next 
stage  in  his  treatment  was  to  get  him  to  sing,  and  after  a  few  weeks' 
practice  he  discovered  that  his  singing  voice  was  practically  as  good 
as  it  ever  had  been.  The  total  treatment  lasted  about  six  weeks,  but 
would  not  have  required  so  much  time  had  the  physician  who  was 
taking  charge  of  it  been  able  to  see  the  patient  every  day. 

The  next  case  also  illustrates  a  probable  regression  to  a 
previous  laryngitis  with  the  production  of  mutism. 

Case  XVI II.  The  patient  is  a  private,  aged  26,  who  had  a  normal 
make-up  apparently  but  was  not  sufficiently  intelligent  to  answer  all 
the  questions  concerning  the  minuter  details  of  his  mental  life.  It 
was  impossible  to  induce  him  to  give  any  data  as  to  his  subjective 
experience — in  fact  he  seemed  to  be  one  of  those  individuals  who 
are  totally  incapable  of  any  introspection.  Before  his  symptoms 
developed  he  had  been  fifteen  months  in  France  and  had  not  received 
a  scratch.  At  first  he  had  been  in  the  Ypres  section,  and  there  had 
been  sickened  by  the  sight  of  wounds,  did  not  like  the  idea  of 
having  to  kill  the  Germans,  and  was  frightened  by  the  shells.  He 
got  used  to  all  these  things,  however,  and  then  rather  liked  the 
warfare.  He  was  particularly  proud  of  the  work  of  the  bombing 
squad  of  which  he  was  a  member.  He  was  able  to  give  no  history 
of  exhaustion  nervousness  or  bad  dreams  before  his  final  accident. 
While  at  Ypres  he  was  gassed  and  laid  up  for  a  week.  He  had  little 
recollection  of  what  symptoms  he  showed  at  that  time  or  of  any 
resemblance  they  might  have  to  the  ones  he  developed  later.  In 
July,  1916,  he  was  blown  up  by  a  shell  which  he  could  remember 
seeing  as  it  burst  at  his  side.     His  companions  told  him  that  he  was 


86 

blown  into  the  air.  He  received  a  wound  in  the  back  and  the  right 
arm  and  lost  a  great  deal  of  blood.  He  was  operated  on  and  came  to 
only  after  several  days.  He  then  fonnd  himself  with  a  bad  headache, 
dizzy,  and  with  consciousness  coming  and  going  for  several  days. 
The  first  time  he  was  conscious  it  lasted  for  only  a  few  seconds. 
The  next  time  a  nurse  was  there  who  spoke  to  him.  He  could  not 
understand  what  she  said  and  tried  to  speak.  He  found  he  could 
not.  This  was  possibly  due  either  to  weakness  or  to  aphasia  which 
so  many  patients  suffering  from  concussion  show  for  a  short  time. 
The  patient  was  also  deaf  for  some  days  and  it  is  possible  that  not 
being  able  to  hear  any  sounds  which  he  did  make  he  developed  the 
idea  that  he  was  really  dumb.  For  some  time  he  was  so  numb  all 
over  that  he  could  not  feel  his  wounds.  This  was  possibly  also  an 
hysterical  symptom  that  was  essentially  a  protective  matter.  At  any 
rate,  he  was  mute  from  then  on.  He  had  difficulty  in  thinking  for 
several  weeks.  His  memory  for  these  first  weeks  was  extremely 
vague  and  he  may  have  been  subjected  to  some  shocks  during  this 
period  which  he  later  forgot.  He  was  at  this  time  in  a  hospital  that 
was  subject  to  bombardment.  And  he  remembers  that  he  was 
"jumpy  "  there,  and  fearful  when  anyone  approached  him.  Night- 
mares began  which  continued  for  a  year  with  gradual  improvement. 
The  setting  of  these  dreams  was  always  in  France  with  a  constant 
content  of  being  wounded  and  having  a  fear  of  death,  the  latter  fear 
predominating  over  any  anxiety  about  wounds.  He  said  that  in 
these  first  weeks  he  thought  of  the  fighting  all  the  time  and  that 
when  the  acuity  of  his  consciousness  would  lapse  he  would  see  the 
trenches  and  the  enemy,  but  did  not  have  any  hallucination  of 
hearing. 

The  patient  was  treated  in  general  hospitals  for  ten  months  and 
showed  no  improvement  whatever  except  in  that  his  dreams  became 
somewhat  less  insistent.  He  was  then  transferred  to  a  special 
hospital  where  improvement  began  at  once  and  had  continued 
steadily  throughout  the  month  that  had  elapsed  before  I  examined 
him.  He  was  then  able  to  speak  and  make  all  the  necessary  voiced 
sounds,  but  suffered  considerably  from  stammering  and  a  distortion 
due  to  over-action  of  the  lips  and  tongue.  He  could  sing,  however, 
with  only  an  occasional  stumbling. 

As  has  been  said,  the  patient  was  not  able  to  give  a  fully 
intelligent  account  of  his  symptoms  or  mental  state  at 
different  times.  Any  explanation  as  to  psychological 
mechanisms  of  his  mutism  must  therefore  remain  purely 
speculations.  There  can  be  no  doubt  that  he  suffered  from 
a  severe  concussion  and  that  the  symptoms  he  showed  on 
recovering  consciousness — weakness,  deafness  and  con- 
fusion— could  be  attributed  directly  to  the  physical  effects 


87 

of  the  concussion.  Whether  the  dumbness  was  due  to  the 
weakness,  the  deafness,  or  was  a  direct  product  of  a  tempo- 
rary aphasia  it  is  impossible  to  say.  Myers  has  suggested 
that  mutism  may  be  psychologically  an  outcome  of  stupor. 
Stupor  is,  he  says,  essentially  a  shutting  out  of  the  en- 
vironment and,  as  speech  is  the  chief  means  of  communi- 
cation which  an  individual  has  with  his  environment,  it  is 
not  unnatural  that  mutism  should  survive  and  represent 
symbolically  the  lack  of  contact  with  his  surroundings.  As 
I  have  not  had  an  opportunity  of  examining  these  cases  at 
this  stage  I  am  not  competent  to  criticise  this  view  with  any 
assurance.  This  would  certainly  be  a  natural  type  of  mech- 
anism and  fits  in  well  with  what  we  know  of  stupors  and 
hysterias  in  times  of  peace,  but  this  applies  to  stupors  that 
are  functional  and  not  organic  in  origin.  In  the  case  just 
quoted,  for  instance,  the  symptoms  of  an  organic  type  are 
suflBciently  evident  to  justify  the  belief  that  the  unconscious- 
ness from  which  he  suffered  was  not  at  all  functional  but 
depended  upon  the  concussion  directly. 

Case  XIX.  The  patient  is  a  corporal  who  was  apparently  normal 
in  mental  make-up  except  for  so:ne  shyness  with  the  opposite  sex. 
He  went  to  France  in  May,  1915,  after  some  months  of  training  to 
which  he  adapted  himself  well.  He  was  at  once  exposed  to  eighteen 
days  of  almost  continuous  bombardment.  He  was  frightened  at  first, 
but  got  used  to  it,  and  settled  down  to  his  work  quite  satisfactorily. 
In  September,  1915,  the  weather  had  been  very  bad  and  he  got  tired 
of  the  situation.  He  began  to  have  bad  dreams.  Most  of  these  were 
of  the  peace  type  of  falling  into  a  deep  hole,  but  he  also  had  night- 
mares of  being  shelled.  His  account  of  this  period  was  rather  indefinite. 
He  admitted,  however,  that  he  was  so  tired  of  the  situation  he 
thought  of  committing  suicide.  He  also  wished  that  a  shell  would 
come  and  give  him  an  incapacitating  wound  or  else  kill  him.  He  be- 
gan to  have  pains  in  his  head,  arms  and  legs,  and  was  feeling  distinctly 
"groggy"  when  a  gas  attack  came.  He  thinks  he  may  have  gotten 
a  whiff  of  the  gas;  at  any  rate  he  felt  giddy,  but  was  able  to  pull  off 
his  mask  for  an  instant  and  take  a  swallow  of  water.  This  made  him 
feel  a  bit  better  and  the  gas  having  passed  he  came  out  of  the  dugout 
into  the  open  air.  He  felt  somewhat  fatigued  after  this  experience, 
however,  and  was  much  relieved  when  his  company  was  ordered 
back  that  night.  Once  back  to  the  lines,  however,  he  got  very  shaky 
and  finally  collapsed,  falling  in  a  heap  on  a  pile  of  straw.  At  the 
time  of  this  collapse  he  did  not  lose  consciousness  at  all.  From  his 
own  account  and  from  notes  made  at  the  hospital  to  which  he  was  im- 


88 

mediately  taken,  it  seems  likely  that  he  had  an  attack  of  acute  articular 
rheumatism.  He  had  a  sore  throat  and  a  pain  in  his  head  which  would 
shoot  down  to  his  left  shoulder  and  to  his  finger  tips,  and  also  shot 
through  his  legs.  The  pain  was  particularly  agonizing  in  the  right 
leg  whenever  his  knee  joint  was  moved.  This  pain  persisted  for  a 
month  after  being  in  the  hospital.  He  said  his  leg  was  like  a  log  from 
the  time  of  this  collapse  on  the  straw.  This  was  an  hysterical  symptom 
of  some  duration,  for  when  the  pains  left  him  after  a  month  in  the 
hospital  his  right  leg  was  paralyzed,  with  an  anaesthesia  of  the  skin 
of  the  whole  leg.  He  was  got  up  out  of  bed  but  he  had  a  gait  typical 
of  hysterical  monoplegia,  and  had  to  walk  with  a  crutch.  The  use  of 
this  led  to  a  crutch  palsy,  and  after  a  month  or  so  he  had  paralysis  of 
the  right  arm,  purely  hysterical,  and  also  accompanied  with  a  super- 
ficial anesthesia.  These  symptoms  persisted  for  eight  months  before 
I  examined  him,  at  which  time  the  power  of  both  arm  and  leg  were 
steadily  improving  with  methods  of  re-education. 

The  mechanism  for  this  conversion  hysteria  seems  fairly 
plain.  The  patient  was  tired  of  the  situation  in  which  he 
found  himself  and  was  anxious  to  receive  some  sort  of  an 
injury  which  would  incapacitate  him  for  active  service. 
Then  he  had  what  was  apparently  an  attack  of  acute  arthri- 
tis in  the  ri^ht  knee  which  caused  him  great  pain  whenever 
his  leg  moved.  The  paralysis,  which  then  developed,  can  be 
easily  explained  as  a  protective  reaction,  since  it  immobil- 
ized the  knee  joint.  The  explanation  for  its  persistence  and 
for  the  development  of  the  paralysis  of  the  arm  is  equally 
simple.  These  disabilities  provided  ample  occasion  for  his 
continued  absence  from  the  front.  It  may  be  added  that 
these  paralyses  were  accompanied  by  the  typical,  hysterical, 
mental  altitude,  for  the  patient  was  unable  to  imagine  him- 
self using  his  leg  at  all. 

But  this  patient  also  showed  other  symptoms.  It  has  been 
mentioned  that  he  wished  for  death  and  that  he  had  had 
some  nightmares  of  fighting.  He  therefore  was  in  the  men- 
tal state  prior  to  his  rheumatism  of  a  man  who  develops  an 
anxiety  condition,  and  had  also  begun  to  show  some  symp- 
toms of  it.  When  he  was  removed  to  the  hospital  he  began 
to  have  more  severe  nightmares,  although  he  never  had  any 
anxiety  symptoms  during  the  day  that  were  at  all  severe  or 
noticeable.  Complicating  the  conversion  hysteria,  there- 
fore, he  had  a  mild  anxiety  state.  This  was  always  in  the 
background,    for   the    dreams  became  infrequent  and  less 


89 

severe  long^  before  there  was    any  improvement   at  all  in 
his  paralysis. 

The  following  three  cases  represent  the  development  of 
hysterical  phenomena  as  a  continuance  of  disabilities  that 
are  more  or  less  organic. 

Casc  XX.  The  patient  is  a  private  in  the  heavy  artillery  who  en- 
listed in  December,  1914,  but  did  not  reach  France  until  March,  1916. 
His  history  showed  that  he  had  some  mild  neurotic  tendencies  inas- 
much as  he  was  afraid  of  high  places,  uncomfortable  in  thunder-storms, 
and  did  not  like  to  go  into  tunnels.  In  other  respects  he  was  quite 
normal  and  seemed  to  have  an  open  personality  and  to  be  quite  sociable. 
He  was  happily  married. 

He  enjoyed  his  work  at  the  front  tremendously  and  the  severe  strain 
of  long  continued  duration  produced  no  symptoms,  not  even  subjec- 
tive fatigue.  On  August  2,  1916,  when  he  had  been  fighting  for  four 
months,  he  was  buried  by  the  earth  thrown  up  from  the  explosion  of 
a  heavy  shell,  and  suffered  severe  concussion.  Consciousness,  that  he 
could  remember,  returned  only  after  three  weeks,  and  following  that 
for  about  ten  days  he  suffered  from  lapses  of  consciousness  whenever 
he  exerted  himself  in  the  slightest  degree.  For  months  he  continued 
to  be  extremely  weak.  Soon  after  recovering  consciousness  for  the 
first  time  he  found  that  he  was  easily  startled  by  sudden  noises,  but 
had  only  occasional  nightmares  of  fighting,  and  absolutely  no  con- 
tinuous anxiety  during  the  day.  He  was,  as  is  often  the  case  after 
severe  concussion,  subject  to  almost  constant  tremors  that  were  inde- 
pendent of  any  conscious  anxiety.  This  "shakiness,"  as  he  termed 
it,  continued  whenever  he  made  any  exertion  for  some  months,  and 
he  found  that  the  only  way  that  he  could  control  it  was  to  cross  his 
legs  and  hold  them  slifHy  in  this  position.  At  first,  of  course,  he 
was  too  weak  to  stand.  Later,  when  his  strength  had  returned,  he  found 
that  whenever  he  would  attempt  to  get  out  of  bed  his  legs  would  go 
immediately  into  an  adductor  spasm  and  shake  violently.  He  was 
treated  with  no  improvement  whatever  in  general  hospitals  for  some 
eleven  months,  and  was  then  transferred  to  a  special  hospital  where  I 
saw  him  only  for  four  days  after  he  had  been  admitted  there.  The 
treatment  given  was  to  stretch  forcibly  the  adductors  of  the  thighs  by 
pulling  his  feet  apart  This  was  continued  until  the  adductor  nuiscles 
were  exhausted  and  incapable  of  further  contraction.  He  was  then  put 
on  his  feet  and,  being  supported,  was  encouraged  to  walk.  For  the 
first  time  he  was  able  to  get  one  leg  past  the  other.  During  the  four 
days  that  had  elapsed  he  had  lost  the  spasm  in  his  left  thigh  almost  com- 
pletely and  was  able  with  an  effort  to  control  that  in  his  right.  The 
tremors  too  had  almost  entirely  disappeared.  He  felt  himself  that  he 
would  be  quite  well  in  a  few  days.  This  case  is  a  dramatic  example 
of  how  simple  a  matter  it  is  to  cure  these  hysterical  symptoms,  in 
spite  of  long  duration,  when  once  rational  treatment  is  employed. 


90 

In  connection  with  this  gait  disturbance  it  might  be  well 
to  recall  Case  IX.  This  patient  it  will  be  remembered  de- 
veloped a  similar  condition  of  spasticity  when  he  attempted 
to  walk  on  leaving  his  bed  for  the  first  time.  With  him, 
too,  the  spasm  developed  as  an  effort  to  control  the  violent 
tremors  of  his  legs,  but  these  tremors  were  probably  much 
more  functional  in  origin  than  those  present  in  the  patient 
whose  history  has  just  been  quoted. 

Case  XXI.  The  patient  is  a  private,  aged  25,  whose  only  neurotic 
tendencies  had  been  a  fear  of  lightning  and  of  snow.  He  had,  how- 
ever, rather  a  poor  personalit3%  enjo3-ing  distinctly  low  ideas  and 
being  rather  given  to  lying,  although  not  at  all  in  a  malicious  way. 
He  enlisted  in  the  regular  armj'  in  1911,  but  deserted  before  long  and 
became  a  professional  foot-ball  player.  When  the  war  broke  out  he 
reenlisted  and  went  to  France  in  September,  1914. 

He  fought  for  six  months  and  claimed  to  have  enjoyed  this  first 
period  of  fighting.  It  was  terminated,  however,  by  an  accident  when 
he  fell  into  a  deep  dugout,  fracturing  both  his  ankles,  and  suffering 
frost-bite  before  he  could  be  taken  back  to  the  hospital.  This  ex- 
perience seems  to  have  given  him  a  distaste  for  the  war.  He  was 
back  in  England  for  three  or  four  months,  and  then  did  not  wish  to 
return  to  France  so  soon.  Even  on  the  way  back  he  began  to  be 
frightened  at  the  prospect.  He  was  kept  for  two  months  in  barracks 
aud  then  went  up  the  line.  He  approached  the  trenches  feeling 
quite  anxious  and,  on  arrival,  got  immediately  into  a  panic  but  was 
saved  from  further  difficulties  bj-  being  wounded  through  the  thigh 
almost  at  once.  This  was  a  minor  injury  but  it  necessitated  his 
remaining  in  a  hospital  for  a  couple  of  weeks.  This  hospital  was 
exposed  to  occasional  shell  fire  and  the  patient  found  that  he  was 
constantly  starting  at  the  noises  and  now  and  again  had  nightmares 
of  fighting,  although  he  would  sleep  through  many  nights  without 
any  disturbance  whatever.  He  was  then  sent  back  to  his  base  for 
some  time,  where  he  had  no  more  nightmares  at  all,  but  was  still 

jump)-  ' '  when  any  particularl}-  loud  noise  would  occur.  A  fear  of 
going  back  to  the  line  had  b}'  this  time  become  a  settled  part  of  his  char- 
acter. He  was  returned  for  three  weeks  to  the  trenches  during  which 
time  he  was  constantl)-  in  fear  but  developed  no  sj^mptoms  whatever. 
This  brief  period  of  fighting  was  again  terminated  when  he  received 
some  superficial  woimds  from  fragments  of  a  shell,  and  this  time  he 
was  fortunate  enough  to  be  sent  back  to  England  for  five  months. 
He  returned  again  in  May,  1916,  and  fought  till  September.  During 
this  time  one  gathers  that  he  tried  hard  to  work  up  the  sjTuptoms  of 
appendicitis  and  trench  fever  but  was  never  able  to  convince  the 
medical  officer  that  there  was  an3-thing  serious  the  matter  with  him. 
He  was  frightened,  of  course,  but  alwa3^s  slept  well  and  had  no  night- 


91 

mares.  In  the  middle  of  September  he  saw  one  of  his  own  men  run 
over  and  crushed  by  a  tank  and,  for  the  first  time,  he  felt  horror. 
From  then  on  any  sight  of  blood  affected  him.  Two  or  three  hours 
after  this  unpleasant  experience  he  was  shot  in  the  right  forearm 
(another  flesh  wound)  which  caused  his  removal  to  a  dressing  station 
and  then  to  a  rest  camp.  He  was  in  the  latter  for  two  weeks,  during 
which  time  he  felt  constantly  afraid  of  returning  to  the  trenches  and 
was  very  loth  to  get  better.  From  the  rest  camp  he  was  sent  to  the 
base  to  join  another  battalion  and  was  then  thrown  into  the  line 
again.  He  was  there  for  three  days,  during  which  time  he  suffered 
considerably  from  his  horror  of  bloodshed  and  from  his  constant  fear. 
He  was  therefore  much  relieved  when  after  only  three  days'  fighting 
he  fractured  his  left  collar-bone  and  left  wrist.  He  was  sent  back  to 
a  casualty  clearing  station,  and  was  only  too  glad  to  give  a  pint  and  a 
half  of  his  blood  for  transfusion  as  he  was  rewarded  for  this  by  being 
shipped  home  to  England.  After  a  few  weeks  his  left  arm  came  out 
of  the  splint,  when  he  discovered  (probably  not  without  satisfaction) 
that  his  arm  was  paralyzed.  He  remained  without  the  use  of  this 
limb  for  five  months  during  which  time  all  kinds  of  treatment  were 
attempted.  He  was  then  sent  to  a  special  hospital  where  simple 
methods  of  reeducation  resulted  quite  quickly  in  the  steady  return  of 
strength  to  his  arm.  It  is  interesting  to  note  that  once  his  hysteri- 
cal paralysis  began  to  improve  he  developed  some  nightmares.  This, 
presumably,  indicates  the  strong  resistance  he  felt  to  the  idea  of 
returning  to  the  front. 

The  following  case  could  perhaps  be  described  as  an 
atypical  anxiety  state  but  is  probably  better  grouped  with 
the  hysterias  inasmuch  as  tremors  and  weakness  and  diges- 
tive disturbances  were  more  prominent  than  the  signs  of 
pure  anxiety.  The  case  is  also  important  as  it  shows  how 
poor  a  soldier  the  individual  makes  who  up  to  the  time  of 
enlistment  has  been  a  highly  neurotic  individual.  It  is  not 
imp)robable  that  his  symptoms  were  typical  because  he  was 
suffering  as  much  from  a  peace  as  from  a  war  neurosis. 

Case  XXir  is  a  private,  aged  23.  He  had  always  been  nervous. 
As  a  child  he  would  scream  if  left  alone  either  day  or  night.  He  had 
such  fear  of  falling  that  he  could  not  approach  a  window.  It  required 
the  greatest  effort  for  him  to  enter  a  subway.  He  was  afraid  of 
lightning.  He  hated  to  see  anybody  fighting,  and  accidents  made 
him  sick.  He  would  pant  with  anxiety  if  he  heard  fire-engine  bells. 
He  also  had  suffered  from  occasional  bilious  attacks.  Frequently  he 
dreamed  that  the  house  was  on  fire.  When  the  Zeppelin  raids  began 
over  London  he  was  terrified  by  them.  He  was  so  seclusive  that  he 
had  never  made  any  friends  with  either  sex,  and  had  such  poor  stuff 
in  him  that  his  brothers  called  him  a  girl  and  not  a  boy. 


92 

This  individual,  so  poorly  adapted  to  civilian  life,  enlisted  in 
October,  1915,  and  went  to  France  four  months  later.  The  training 
in  an  artillery  company  did  him  good  physically,  taut  it  led  to 
further  difficulties  mentally  and  nervously.  He  could  not  make  any 
friends  and  was  constantly  afraid  of  doing  things  wrong.  Fear  of 
the  fighting,  that  was  to  come,  increased  steadily  as  the  time  grew 
near  when  he  would  have  to  go  to  the  front.  On  reaching  France  he 
was  at  first  back  of  the  front  line  of  trenches,  and  consequently  he 
saw  very  little  fighting  for  some  time.  Some  enemy  aeroplanes 
appeared,  however,  which  scared  him  horribly,  and  for  some  nights 
he  could  not  get  to  sleep  thinking  of  them.  For  the  first  month  he 
was  busy  carrying  rations  and  munitions  from  the  rear  up  to  the 
communication  trenches;  then  he  began  to  work  with  his  battery. 
For  the  first  three  weeks  the  battery  remained  immune  from  attack; 
then  it  was  shelled.  The  patient  was  frightened  horribly  and  could 
not  help  crying  out  "What  a  terrible  one  that  was!"  whenever  a 
shell  came.  He  was  promptly  told  to  keep  quiet  but  was  unable  to 
do  so.  In  subsequent  bombardments  he  would  listen  attentively  to 
the  successive  reports  from  the  guns,  and  convince  himself  that  the 
enemy  guns  were  coming  closer.  The  first  sight  of  the  wounded 
affected  him  so  extremely  that  he  almost  cried,  although  somehow  or 
other  he  managed  to  get  used  to  this  suificiently  for  him  to  continue 
at  work.  From  the  time  when  he  first  approached  the  line,  however, 
he  began  to  dream  of  the  enemy  coming  after  him  with  bayonets. 
These  nightmares  of  course  disturbed  his  sleep,  and  he  also  had  great 
difficulty  in  getting  to  sleep  at  all  when  he  lay  down  to  rest. 
Although  he  got  gradually  worse  he  somehow  or  other  managed  to 
continue  in  his  ineffective  way  for  some  nine  months.  His  battery 
was  finally  relieved  and  sent  to  a  rest  camp  where  he  at  once  felt  a 
little  better.  Then  a  false  report  came  that  the  battalion  was  to  re- 
turn to  the  front.  The  patient  at  once  collapsed.  He  could  not  stand, 
was  shaking  all  the  time,  crying  and  vomiting.  The  nightmares 
became  so  severe  that  he  could  not  sleep  at  all  for  four  nights  after 
his  admission  to  a  hospital.  For  some  days  also  he  was  able  to  keep 
nothing  whatever  on  his  stomach,  and  during  the  six  months  that 
had  elapsed  since  that  time  when  I  saw  him  he  had  not  eaten  a  single 
full  meal.  He  was  sent  back  to  England  and  treated  in  various  hos- 
pitals. He  improved  twice,  being  able  once  to  walk  from  one  bed  to 
another,  although  he  often  fell  with  giddiness,  after  which  he  would 
shake  terribly  and  sweat  profusely.  This  improvement  lasted  for  a 
week.  There  was  then  some  talk  of  his  being  sent  to  a  convalescent 
hospital.  The  patient  began  to  fear  that,  if  he  recovered,  he  would 
be  sent  back  to  France,  and  although  this  was  more  a  passing  idea 
than  a  constant  worry,  it  may  explain  the  fact  that  he  fell  down  again 
when  this  transfer  was  imminent  and  was  not  able  to  get  up  again. 
He  was  sent  to  the  convalescent  home,  however,  where  he  improved 
again,  this  time  with  electrical  treatment.     He  got  so  that  he  could 


93 

walk  but  then  pains  developed  in  his  back  and  across  his  hips  which 
soon  put  a  stop  to  his  walking.  He  had  been  told  that  he  would  not 
be  sent  from  the  convalescent  home  to  a  special  hospital  i:nless  he 
became  worse  again,  and  probably  this  is  what  caused  the  develop- 
ment of  the  pains.  When  I  saw  him  he  had  been  in  this  special  hos- 
pital for  ten  days  during  which  time  he  had  become  much  less  shaky 
although  he  was  still  unable  to  walk.  He  had  a  rigidity  of  the  muscles 
along  his  spine  and  some  diminishing  signs  of  hyperthyroidism. 
His  dreams  had  become  much  belter — that  is  his  nightmares  of  being 
bayoneted  were  tending  to  disappear,  biit  he  was  troubled  with  other 
nightmares  of  the  peace  type;  for  instance  he  would  dream  that  the 
hospital  was  on  fire,  or  that  Zeppelins  were  going  to  come.  Once 
while  sleeping  on  a  balcony  he  dreamed  that  it  collapsed  but  that  he 
hung  on  to  the  edge  with  his  fingers.  He  awoke  screaming  to  the 
nurse  to  come  and  rescue  him. 

The  following  case  shows  how  an  anxiety  state  in  an 
officer  can  be  inhibited  from  further  development  when  other 
symptoms  develop — in  this  case  symptoms  of  a  gastric 
neurosis. 

Case  XXIII.  The  patient  is  a  lieutenant,  aged  24.  He  had  never 
had  any  illness  in  his  life,  but  had  always  been  of  a  high-strung 
nervous  temperament.  He  was  afraid  of  the  dark  as  a  child  and  had 
night  terrors.  These  were  mainly  of  falling  into  a  huge  funnel  and 
being  jammed  in  the  bottom.  He  had  had  no  fear  of  thunder-storms 
or  of  tunnels,  but  would  become  rather  excited  and  could  not  trust 
himself  if  he  were  in  a  high  place.  He  was  shy  with  girls  and  saw 
nothing  of  them  until  he  left  school  at  18,  but  thought  that  he  had 
improved  somewhat  in  this  respect  as  he  grew  older — in  fact  he  has 
recently  become  engaged.  His  social  relationships  with  those  of  his 
own  sex  were  apparently  quite  normal.  It  is  important  to  note  that 
he  had  always  been  sensitive  to  pain  and  more  than  normally  sympa- 
thetic. Once  when  he  was  a  boy  a  companion  took  him  into  a 
butcher's  yard  to  see  a  pig  killed.  This  upset  him  greatly  and  he 
felt  excited  for  some  time  after. 

He  enlisted  as  a  private  in  September,  1914,  and  reacted  well  to  his 
training  except  that  he  was  troubled  with  a  little  fear  of  being  a 
coward  in  France.  He  conquered  this,  however,  to  the  point  of  being 
able  to  look  forward  to  the  trial,  and  when  he  went  there  in  March, 
1915,  he  was  pleased  to  find  that  his  nerve  was  as  good  as  that  of  the 
rest.  He  got  used  to  being  shelled  quite  quickly  but  found  in  the 
nine  months  of  fighting,  during  which  he  served,  that,  so  long  as  he 
was  in  perfect  physical  condition,  he  had  the  feeling  that  nothing 
could  hurt  him,  but  that  whenever  he  became  tired  this  conviction 
would  disappear.  After  seven  months  of  fighting  he  was  exposed  to 
a  monotonous  bombardment  with  howitzers  for  three  days.     He  and 


94 

his  comrades  were  in  an  advanced  "  bay  "  and  it  was  only  a  question 
of  time  before  every  man  would  be  killed  in  all  probability.  Nothing 
happened  to  him,  however,  before  he  was  relieved.  He  was  calm 
mentally  but  could  not  stop  shaking  for  three  hours  after  leaving  the 
trenches.  Following  this  experience  he  was  "jumpy  "  and  felt  dis- 
appointed in  himself.  He  did  not  lose  sleep,  however,  or  have  any 
nightmares,  but  found  it  gradually  more  difficult  to  control  himself 
whenever  a  methodical  bombardment  was  in  progress.  In  December, 
1915,  he  was  sent  back  to  England  to  receive  training  as  an  offi::er, 
which  lasted  for  six  months.  He  was  glad  of  the  rest  but  disappointed 
to  find  that  it  did  not  do  him  so  much  good  as  he  had  hoped.  He 
went  to  work  to  have  as  good  a  time  as  possible  because  he  expected 
that  he  would  be  killed  when  he  went  back  to  France.  He  was  much 
more  worried  at  the  thought  of  going  to  pieces  nervously  than  by  any 
fear  of  death  itself.  He  went  back  as  lieutenant  in  June,  1916,  and 
found  that  it  cost  more  effort  than  before  to  control  his  fear.  The 
strain  of  constantly  encouraging  his  men  told  on  him.  He  did  not 
actually  lose  sleep,  but  always  felt  heavy  when  he  awoke  in  the  morn- 
ing. Trench  mortars  were  very  active  in  his  section  of  the  line  and 
the  frightful  explosions  from  them  constantly  upset  him.  His  whole 
spirit  grew  weary  of  the  war.  So  far  his  history  is  qtiite  typical  of 
the  prodromal  period  of  an  anxiety  state. 

The  sight  of  blood  had  not  bothered  him  at  any  time,  although 
seeing  a  man  blown  to  bits  or  losing  a  comrade  always  upset  him.  He 
felt  distinctly  encouraged  when  he  saw  dead  Germans.  After  being 
nearly  four  months  in  France  as  an  officer  a  shell  blew  up  a  group  of 
men  right  beside  him.  One  of  them  remained  sitting  down  with  his 
back  against  the  wall  of  a  trench  and  the  patient  thought  that  he  was 
alive.  He  went  up  to  him  and  touched  him  on  the  helmet.  Im- 
mediately the  whole  back  of  the  man's  head  rolled  off  and  exposed 
the  back  of  his  eyes  and  his  nose  and  teeth.  This  sight  gave  the 
patient  a  terrible  "turn."  He  went  into  the  dugout  and  trembled  for 
several  hours.  He  did  not  feel  any  nausea  but  when  the  time  next 
came  to  eat  he  discovered  that  he  had  absolutely  no  appetite,  and 
from  that  time  on  it  required  a  great  effort  to  put  any  food  in  his 
mouth.  In  describing  this  incident  the  patient  emphasized  the  fact 
that  he  was  merely  a  calm  observer  of  the  tragedy.  He  felt  that  if 
the  shell  had  knocked  him  over  it  would  have  given  him  some  degree 
of  relief.  From  then  on  he  began  to  feel  horror  of  all  bloodshed  and 
was  quite  incapable  of  developing  any  excitement  no  matter  how 
active  the  fighting  might  be.  He  felt  that  all  individuality  in  the 
struggle  was  lost  and  that  it  was  a  pure  matter  of  siege  warfare.  He 
could  gain  no  satisfaction  in  killing  one  or  many  of  the  enemy.  His 
sleep,  however,  was  not  interfered  with  and  he  had  no  nightmares. 

While  in  this  condition  (October,  1916)  he  was  transferred  to  Salo- 
nika. There  was  no  active  fighting  there,  but  sufficient  exertion  was 
demanded  to  cause  fatigue,  particularly  since  he  was  eating  little  or 
nothing.     In  making  a  landing  on  the  coast  from  the  transport  he 


95 

got  wet  and  had  not  an  opportunity  of  changing  his  clothes  for  several 
days.  Shortly  after  this  a  neuralgic  pain  appeared  in  his  mouth. 
Previously,  however,  he  had  begun  to  suffer  from  flatulence.  The 
next  symptom  to  develop  was  constipation,  the  faecal  matter  being 
foul,  and  he  began  to  have  nausea  whenever  his  bowels  did  move. 
Possibly  as  a  result  of  the  restricted  diet,  which  was  mainly  canned 
beef  and  biscuits,  pyorrhea  began  to  develop.  Although  he  was 
thoroughly  miserable  his  symptoms  remained  in  the  physical  sphere, 
except  once  when  an  enemy  airplane  flew  over  the  lines.  They  fared 
at  it  with  anti-aircraft  guns,  and  this  incident  excited  the  patient  so 
much  that  he  knew  his  nerve  was  no  better.  After  suffering  for  three 
weeks  with  neuralgia  he  asked  to  be  sent  to  the  hospital,  which  re- 
quest was  granted.  He  was  there  for  three  weeks,  and  then  was  sent 
to  the  base  depot.  The  food  was  worse  than  any  supplied  previously 
and  after  three  days  he  began  to  vomit  and  was  sent  back  to  the  hos- 
pital where  he  was  put  on  a  milk  diet.  As  all  tests  were  negative  it 
was  concluded  that  he  was  suffering  from  a  gastric  neurosis,  and  he 
was  shipped  to  IMalta  where  he  was  kept  for  three  or  four  months  and 
then  sent  home  to  England.  While  in  Malta  there  was  no  improve- 
ment in  his  condition  and  he  settled  down  to  the  belief  that  he  was 
a  confirmed  invalid.  In  England  he  was  put  in  a  special  hospital 
where  he  had  improved  slightly  at  the  time  that  I  saw  him.  His 
neuralgia  had  almost  entirely  left  him  and  the  vomiting  had  disap- 
peared. He  still  had  no  appetite,  however,  and  frequently  suffered 
from  nausea  either  before  or  after  eating.  Constipation  was  alter- 
nating with  diarrhea.  Mentally  he  complained  of  a  lack  of  interest 
and  spontaneity.  He  said  he  had  forgotten  his  education — that  his 
youth  and  his  eagerness  were  all  gone.  In  explaining  his  poor 
adaptation  to  fighting  he  said  that  he  thought  that  the  strain  told  on 
him  because  of  his  imagination.  It  was  impossible  for  him  to  keep 
the  belief  from  his  mind  that  every  shell  was  meant  for  him. 

In  this  case,  therefore,  we  have  a  patient  who  had  always 
had  some  neurotic  tendencies  although  they  had  never 
incapacitated  him  during-  civilian  life.  One  of  these  was 
an  undue  sensitiveness  to  cruelty  or  bloodshed.  After  some 
months  of  fighting  the  strain  began  to  tell  on  him,  his 
condition  growing  steadily  worse,  and  it  seems  as  if  the 
normal  development  of  his  difficulties  would  have  led  to  a 
typical  anxiety  state.  Up  to  this  time,  however,  he  had 
always  remained  more  or  less  immune  to  the  horrors  of  war. 
Then  suddenly  a  particularly  fearful  experience  branded 
horror  on  his  mind  and  symptoms  of  another  kind  developed 
at  once.  From  then  on  the  pathological  tendencies  seemed 
to  flow  in  the  direction  of  a  gastric  neurosis  rather  than  in 
the  ordinary  channel  of  an  anxiety  state. 


96 

Heart  Neuroses. 

In  times  of  peace  certain  symptoms  related  to  the  function 
of  the  heart  are  frequent  concomitants  of  anxiety  conditions 
— in  fact  fear  of  death  may  be  directly  associated  with  fear 
that  heart  failure  is  imminent.  Except  for  some  rapidity 
of  the  pulse  of  which  the  patient  is  often  not  aware  the 
typical  war  anxiety  neurosis  shows  nothing  of  this  tendency. 
There  is,  however,  rather  a  large  group  of  men  who  are 
invalided  from  the  trenches  with  heart  symptoms  but  who 
show  no  signs  of  valvular  trouble.  These  cases  have  been 
termed  "soldier's  heart"  or  "disordered  action  of  the 
heart."  The  cardinal  symptoms  of  this  cardiac  trouble  are 
weakness,  shortness  of  breath,  palpitation  and  dizziness. 
Not  infrequently  there  is  an  area  of  hyperalgesia  over  or 
near  the  heart.  Owing  to  the  obvious  analogy  between 
these  symptoms  and  those  presented  by  the  cardiac  difficul- 
ties of  civilians  suffering  from  anxiety  it  has  been  suggested 
that  the  "  disordered  action  of  the  heart"  is  really  a  form 
of  the  war  anxiety  neurosis.  Some  internists  who  have 
been  engaged  in  treating  these  cases  make  the  statement 
that  50  per  cent  are  really  neurotics.  The  word  neurotic 
is  one,  of  course,  that  is  used  in  widely  varying  senses. 
By  some  it  is  an  adjective  to  describe  any  physical  symptom 
that  has  not  an  obvious  physical  cause,  being  therefore 
equivalent  to  functional  disturbance.  The  narrower  sense 
of  the  term  implies  a  mental  condition  which  shows  itself 
in  certain  types  of  reaction  and  produces  or  tends  to  produce, 
somehow  or  other,  physical  symptoms.  Those  who  use  the 
term  in  the  narrower  sense  find,  for  instance,  that  prior  to 
the  appearance  of  active  symptoms  the  patient  gives  a 
history  of  being  subjected  to  some  mental  conflict  or  having 
suffered  from  some  mental  shock.  Neurologists  or  psychi- 
atrists who  have  this  view  would  not  call  disturbances  of 
the  ductless  glands,  e.  g.,  hyperthyroidism,  neuroses. 

Work  which  has  been  done  by  Frazer  and  Wilson  at  the 
Hampstead  Hospital  (for  heart  cases)  in  London  seems  to 
indicate  that  a  large  number  of  these  cases  are  suffering 
from  some  irregularity  of  function  in  the  endocrinic  or 
vegetative  nervous   systems.     The   administration  of  very 


97 

small  quantities  of  adrenalin,  for  instance,  they  find  to 
produce  excessive  excitement,  great  pallor,  discomfort  and 
real  collapse,  although  there  is  no  change  in  the  pulse  rate. 
On  the  other  hand,  small  doses  of  apocodein  result  in 
flushing  even  to  the  point  of  erythema  accompanied  by 
extreme  tachycardia.  Atropin  on  the  other  hand  even  in 
full  doses  produces  no  effects  whatever.  A  few  patients, 
who  were  treated  experimentally  with  small  doses  of  pineal 
extracts,  showed  vomiting  and  collapse.  These  results 
would  certainly  seem  to  indicate  that  these  patients  were 
suffering  from  some  definite  disturbances  of  the  mechanism 
which  regulates  the  action  of  the  heart  and  are  therefore 
definitely  organic,  although  not  suffering  from  valvular 
diseases.  This  view  is  sustained  by  the  histories  which 
show  as  a  rule  that  these  individuals  have  never  been 
capable  of  a  normal  amount  of  exertion — for  instance,  they 
have  been  unable  to  play  any  games  that  demanded 
endurance,  although  capable  of  taking  part  in  such  milder 
sports  as  golf.  It  has  been  found  that  this  lack  of  vitality 
of  the  heart  can  be  quickly  determined  by  an  "exercise 
test."  The  patient's  pulse  is  counted  and  he  is  then  made 
to  go  briskly  up  a  flight  of  thirty  steps.  His  pulse  is  taken 
immediately  and  then  again  after  he  has  rested  for  two 
minutes.  The  normal  individual  will  show  a  rise  of  40  or 
perhaps  45  in  the  pulse  rate  after  this  exertion,  but  this 
falls  after  two  minutes'  rest  back  to  the  original  rate  or  to 
within  10  or  at  most  15  of  it.  Patients  who  suffer  from 
"  disordered  action  of  the  heart,"  however,  may  show  an 
increase  of  rate  of  60  or  more  and  the  pulse  does  not  slow 
down  again  after  two  minutes'  rest,  or  at  least  will  slow 
only  in  slight  measure. 

In  order  to  see  whether  from  a  psychiatric  standpoint 
they  were  really  "neurotic"  I  examined  some  ten  cases 
with  a  view  to  determining  what  their  mental  and  emotional 
history  had  been.  These  cases  were  very  kindly  picked 
out  for  me  by  Dr.  Wilson  as  ones  most  likely  to  be 
purely  neurotic.  I  was  able  to  make  diagnosis  of  a  true 
neurosis  in  only  two  of  these  cases,  and  in  all  of  them  a 
prediction  as  to  the  result  of  the  exercise  test  was  found  to 


98 

be  accurate  when  reference  was  made  to  the  notes  on  the 
patient.  Although  this  is  of  course  too  small  a  number  to 
make  an}^  deductions  in  the  form  of  percentages,  the  results 
are  nevertheless  suflBciently  striking  to  justify  one  in 
assuming  that  the  majority  of  the  patients  who  suffer  from 
'disordered  action  of  the  heart"  are  not  neurotics  in  the 
narrow  sense  of  the  word.  A  few  illustrative  cases  may  be 
quoted.  The  first  gives  an  example  of  the  purely  organic 
and  non-neurotic  type  of  disease. 

Case  XXIV.  The  patient  is  a  private,  aged  29,  who  enlisted  in 
February,  1917,  in  a  labor  battalion  and  did  clerical  work  in  a  casualty 
clearing  station  in  France.  He  had  never  been  able  to  keep  up  any 
severe  exertion  and  for  this  reason  had  to  restrict  his  activities  in 
athletics.  All  his  life  he  was  subject  to  palpitations  of  the  heart  and 
would  frequently  wake  up  with  a  choking  feeling  at  night,  although 
he  had  not  had  any  bad  dreams  that  he  could  recall.  When  his  sleep 
was  thus  disturbed  he  would  have  a  terrible  sensation,  with  difficulty 
in  getting  himself  fully  awake.  On  the  other  hand  he  seems  to  have 
been  emotionally  a  normal  individual.  He  suffered  from  no  night 
terrors  as  a  child  and  had  none  of  the  ordinary  neurotic  fears  or 
sensibilities  except  a  slight  giddiness  in  high  places,  which  is  a 
symptom  that  affects  almost  everyone  whether  he  be  otherwise 
neurotic  or  not.  He  was  never  given  to  worry.  He  had  been  a 
normal  mischievous  boy,  had  never  had  any  shyness  with  either  sex, 
and  at  the  time  when  I  examined  him  had  been  married  for  five  years 
and  professed  himself  happier  since  his  marriage  than  he  had  ever 
been  before. 

In  his  work  in  the  casualty  clearing  station  he  was  of  course 
exposed  to  shell  fire  at  times.  This  bothered  him  only  temporarily. 
The  sight  of  the  wounds  also  affected  him  with  horror  for  a  short  time 
only,  after  which  he  became  fully  accustomed  to  both  forms  of  strain. 
He  had  no  nightmares.  On  the  other  hand  the  physical  exertion 
that  was  necessary  told  on  him  gradually  more  and  more  and  his 
previous  symptoms  of  palpitation  and  nocturnal  choking  got  so  bad 
that  he  could  not  continue  working  and  he  was  sent  to  a  hospital. 
All  during  this  time  he  had  no  anxiety  whatever  and  was  bitterly 
disappointed  to  find  that  he  had  to  stop  '  'doing  his  bit. ' '  The  exercise 
test  showed  that  he  had  an  initial  pulse  of  120  which  rose  to  168  after 
exertion  and  fell  only  to  144  after  two  minutes'  rest. 

The  following  two  cases  exhibited  the  more  neurotic 
reaction. 

Case  XXV.  The  patient  is  a  private,  aged  20.  As  a  child  he  had 
night  terrors  and  was  subject  to  sleep  walking  until  8  years  of  age. 
He  was  always  anxious  during  thunder-storms  and  giddy  in  high 


99 

places,  although  he  admitted  no  uncomfortableness  in  tunnels.  He 
made  some  boy  friends  but  was  very  shy  with  girls  and  not  at  all 
mischievous.  lie  had  never  had  any  serious  disease  although  he  had 
a  slight  attack  of  tonsilitis  at  the  age  of  6  from  which  he  recovered 
without  any  subsequent  complications.  He  was  able  to  play  games 
as  a  boy  and  was  particularly  fond  of  foot-ball,  but  gave  it  up  when 
he  was  14  because  he  found  that  he  was  getting  short  of  breath. 
Considering  that  he  was  incapable  of  exertion  prior  to  this  time,  it  is 
not  impossible  that  this  dyspnoea  coming  on  at  the  time  of  puberty 
was  a  neurotic  symptom,  since  so  many  neuroses  begin  at  this  time. 

The  training  did  him  good  as  he  made  more  friends  than  he  ever 
had  before.  At  first  he  found  himself  considerably  fatigued  with  the 
efforts  demanded  of  the  recruits,  but  he  improved  in  this  as  the 
training  went  on.  When  he  reached  the  front  he  was  frightened  only 
temporarily  by  the  shells  but  never  could  accustom  himself  to  all  the 
horrors  of  war.  He  fought  for  seven  months,  when  he  was  invalided 
home  for  six  months  with  "septic  poisoning."  On  his  return  to  the 
front  in  July,  1916,  he  felt  nervous  again  at  first  but  got  used  to  it 
once  more.  In  September,  he  began  getting  pains  in  his  side,  for 
which  he  was  sent  to  the  hospital.  There  he  had  no  fever  and  the  pains 
quickly  disappeared  and  remained  absent  while  he  was  convalescent 
for  a  month.  As  soon  as  he  returned  to  the  trenches,  however,  they 
reappeared.  His  condition  grew  severe  enough  to  justify  hospital 
treatment  in  December,  1916,  at  which  time  he  was  away  from  the 
trenches  for  three  months.  On  his  return  to  them  again  he  lasted 
only  three  weeks,  and  for  the  next  three  months,  at  the  end  of  which 
time  I  saw  him,  he  had  been  traveling  from  hospitals  to  convalescent 
camps  and  back  again. 

Evidence  of  there  being  definitely  neurotic  prodromata  is  furnished 
by  the  following  information  which  he  gave:  Before  any  heart  symp- 
toms developed  he  had  become  "nervous."  He  was  "jumpy  "  during 
the  day  and  frequently  awoke  at  night  with  a  start.  He  also  had  diffi- 
culty in  getting  to  sleep.  He  was  thoroughly  dissatisfied  with  his 
situation  and  had  reached  the  point  where  he  hoped  that  he  might  re- 
ceive some  incapacitating  wound.  This  situation  is  therefore  identical 
with  that  which  one  usually  meets  in  the  history  of  the  typical  con- 
version hysteria,  and  it  is  also  like  that  rather  than  resembling  the  anx- 
iety state  in  that  he  had  no  desire  for  death  and  no  thoughts  of  suicide. 
The  symptoms  began  after  he  had  been  in  this  state  of  mind  for  some 
time,  and  consisted  at  first  merely  of  a  pain  in  the  region  of  his  heart. 
The  subsequent  difficulties  with  palpitation,  shortness  of  breath  and 
weakness  developed  later  on.  There  is,  therefore,  nothing  in  this 
case  that  points  definitely  to  any  organic  condition,  and,  on  the  other 
hand,  the  evidence  does  seem  to  indicate  that  the  heart  symptoms 
were  essentially  hysterical  in  nature.  This  is  confirmed  by  the  exer- 
cise test  which  showed  him  to  have  a  pulse  of  75  before  exertion,  108 
immediately  after  running  up  the  thirty  steps,  and  only  84  when  he 
had  rested  two  minutes. 


100 

Case  XXVI.  The  patient  is  a  gunner,  aged  35,  an  Australian.  He 
seems  to  have  had  a  distinctly  neurotic  make-up.  As  a  child  he  had 
night  terrors  with  dreams  of  falling.  He  was  always  horrified  at  the 
sight  of  blood  and  was  afraid  of  thunder-storms,  high  places,  tunnels 
and  horses.  He  does  not  seem  to  have  been  a  normal  mischievous 
boy,  and  when  he  grew  older  was  shy  with  both  sexes.  He  had  had 
only  one  love  affair,  which  he  broke  off  in  1911  for  no  apparent 
reason.  His  training  was  of  benefit  physically  but  not  mentally  or 
nervously  and  he  showed  no  increased  sociability  during  it.  His 
first  service  was  in  Egypt.  On  the  way  there  he  developed  a  fear  of 
shipwreck  which  was  not  shared  by  his  companions.  He  was  in  Egypt 
for  some  months,  and  although  there  was  no  fighting,  he  fouad  the 
weather  hot  and  uncomfortable  and  he  suffered  from  occasional 
palpitations  and  "sinking  feelings  "  which  he  ascribed  to  the  heat. 

He  was  then  transferred  to  the  French  Front  in  May,  1916.  In  his 
initial  experience  of  being  shelled  he  became  first  terrified  and  then 
dull  and  depressed.  He  was  horrified  by  the  sight  of  blood  and  would 
think  about  it  whenever  he  was  not  busy.  He  never  was  able  to  reach 
the  point  of  enjoying  any  of  the  fighting.  He  soon  began  having 
peculiar  sensations  when  going  off  to  sleep  as  if  he  were  sinking,  or 
that  his  soul  was  leaving  his  body,  and  he  would  have  to  sit  up  in  bed 
two  or  three  times  to  get  rid  of  this  queer  feeling.  He  also  would 
awaken  with  sudden  starts,  although  not  having  any  memory  of  a  bad 
dream.  Things  got  gradually  worse  and  then  he  began  to  have  night- 
mares of  "things"  (mainly  shells)  falling  on  him.  He  would  try  to 
get  away  from  them,  but  could  not.  His  sleep  consequently  began  to 
be  much  worse,  and  he  worried  for  fear  he  would  not  be  able  to  stick 
it  out.  He  wished  that  death  might  come,  but  never  had  a  hope  of 
receiving  an  incapacitating  wound.  He  frequently  thought  of  suicide. 
At  the  beginning  of  May,  1917,  he  was  blown  off  his  feet  by  a  shell. 
This  did  not  injure  him  physically  apparently  but  disturbed  him  men- 
tally a  great  deal.  From  that  time  on  he  felt  that  the  shells  were  being 
aimed  at  him,  and  four  days  after  this  experience  he  developed  a  pain 
in  his  side,  trembling  and  difficulty  in  breathing.  He  said  his  throat 
swelled  up  and  he  felt  as  if  he  were  going  to  choke.  He  attributed 
this  to  being  gassed,  although  he  had  not  been  exposed  to  this  any 
more  than  had  his  companions,  who  showed  no  symptoms  of  it.  As 
he  had  been  wishing  for  death  it  is  not  unnatural  that  he  should  have 
looked  on  this  choking  sensation  as  a  forerunner  of  death  and  he 
quickly  concentrated  most  of  his  fear  on  this  symptom  which  nat- 
urally made  it  much  worse.  He  claims  that  it  once  was  so  bad  that 
he  "went  black  in  the  face  "  and  he  got  so  short  of  breath  and  trem- 
ulous that  the  bombardier  sent  him  back  to  a  hospital.  Once  in  the 
hospital  he  grew  weaker  and  weaker  and  was  so  terrified  by  his  dreams 
that  he  would  scream  aloud  on  awakening  from  them.  After  six 
weeks  in  a  special  heart  hospital  all  the  symptoms  directly  related  to 
the  heart  cleared  up  although  he  was  still  troubled  occasionally  with 


101 

suffocating-  feelings  during  the  night  which  continued  to  frighten  him, 
the  fear  being  always  of  instant  dissolution.  Nightmares  with  a  war 
content  had  entirely  disappeared,  although  he  still  had  occasional 
dreams  of  falling.  There  was  no  evidence  of  any  organic  trouble 
which  could  have  caused  the  feeling  of  suffocation.  The  exercise  test 
showed  an  initial  pulse  of  96  running  up  to  168  after  exercise  but 
falling  to  84  after  two  minutes'  rest. 

The  history  of  the  following  patient  is  interesting  as  it 
seetns  to  demonstrate  the  existence  of  both  organic  and 
neurotic  factors.  It  appears  that  he  had  the  prodromal 
symptoms  of  a  neurosis  the  further  development  of  which 
was  essentially  organic.  As  has  been  said  before,  a  large 
part  of  the  motivation  of  any  neurosis  comes  from  a  desire 
to  be  rid  of  trench  life.  When  any  real  occasion  for  absence 
from  the  firing  line  appears  there  is  therefore  little  reason 
left  for  the  development  or  continuance  of  the  true  neurosis. 

Case  XXVII.  The  patient  is  a  private,  aged  19,  who  enlisted  in 
the  territorials  in  January,  1914,  but  did  not  reach  France  until  Septem- 
ber, 1916.  As  a  child  he  had  had  night  terrors  and  some  fear  of  the 
dark  which  persisted  up  to  the  time  when  he  enlisted  at  the  age  of  16. 
He  had  no  fear  of  thunder-storms  but  was  giddy  in  high  places  and 
would  break  out  into  a  cold  sweat  and  tremble  whenever  he  had  to  go 
through  a  tunnel.  He  suffered  from  enuresis  until  10  years  of  age 
and  from  puberty  onward  had  considerable  worry  about  emissions. 
He  does  not  seem  to  have  been  particularly  seclusive  so  far  as  his 
social  adaptations  are  concerned.  He  was  good  at  games  but  always 
had  a  tendency  to  shortness  of  wind.  When  he  began  training  he 
was,  of  course,  only  16  years  of  age  and  had  considerable  difficulty  in 
carrying  his  pack  at  first.  Then  he  got  used  to  it  and  felt  distinctly 
stronger.  When  he  reached  France  he  found  the  life  in  the  trenches 
distasteful.  He  could  not  accustom  himself  to  the  horrors  around  him 
and  worried  over  them  constantly.  He  was  never  able  to  make  him- 
self perfectly  indifferent  to  bombardment.  He  began  quite  soon  to 
wish  that  he  might  be  killed  or,  at  any  rate,  be  removed  from  the 
trenches  for  some  cause  or  other.  He  had  no  nightmares,  however, 
and  did  not  lose  any  sleep.  Then  pains  developed  under  his  heart, 
accompanied  by  shortness  of  breath,  palpitation,  dizziness,  and  a  feel- 
ing of  faintness.  He  connected  these  heart  symptoms  with  the 
previous  "weakness  of  his  bladder"  from  which  he  had  suffered 
(enuresis)  but  did  not  worry  about  them  more  than  he  did  about  the 
shells.* 

*  Although  not  a  final  diagnostic  point  by  any  means,  this  emotional  attitude 
of  indifference  toward  the  heart  symptoms  is  suggestive  of  an  organic  rather 
than  a  functional  condition.  The  ideas  of  heart  disease  and  death  are  closely 
allied;  so  we  find  as  a  rule  that  a  fear  of  death  is  frequently  associated  with 
neurotic  heart  symptoms — in  fact,  as  in  the  last  case,  the  neurotic  "cause  of 
death  "  is  apt  to  occasion  more  fear  than  a  real  cause. 


102 

The  medical  officer  sent  him  off  duty  several  times  for  treatment  of 
his  heart  trouble.  After  three  months  in  the  trenches  and  having^ 
been  sent  to  the  hospital  for  short  periods  several  times  he  developed 
"trench  feet"  and  was  sent  back  to  England.  His  heart  condition 
then  attracted  attention  and  he  was  transferred  to  a  special  hospital 
where  I  saw  him.  On  admission  the  pulse  test  was  positive — that  is, 
the  rate  did  not  diminish  as  it  normally  does  after  two  minutes'  rest. 
After  being  treated  for  several  months  with  graduated  exercises  he 
was  capable  of  going  through  the  heaviest  routine  and  the  pulse  test 
had  become  negative.  It  is  therefore  likely  that  the  cardiac  mech- 
anism had  recovered  very  largely  in  a  purely  organic  sense.  The 
patient  still  insisted,  however,  that  his  heart  trouble  was  not  getting 
any  better.  One  might  therefore  be  justified  in  suspecting  that  this 
patient  was  rather  consciously  hoping  for  a  persistence  of  his 
symptoms. 

Although  the  heart  cases  examined  for  the  purpose  of  this 
report  were  too  few  in  number  to  justify  any  finality  in  the 
discussion  of  the  mental  mechanisms  involved,  it  may  be 
suggested  that  there  are  perhaps  two  types  that  correspond 
roughly  to  the  anxiety  and  the  conversion  hysteria  groups. 
Some  heart  cases  like  Case  XXVI  seem  to  have  a  very  strong 
coloring  of  anxiety,  and  this  is  associated  with  a  desire  for 
death  as  a  form  of  relief  before  the  actual  appearance  of  the 
symptoms.  In  the  other  group  as  represented  by  Case  XXV 
a  wish  for  an  incapacitating  wound  rather  than  for  death  is 
present  in  a  prodromal  state  and  when  the  heart  symptoms 
develop  they  are  looked  on  more  objectively  as  a  disease  and 
are  not  accompanied  by  the  same  anxiety.  This  feeble 
emotional  reaction  to  the  symptoms  is  therefore  closely  par- 
allel to,  if  not  identical  with,  the  phenomena  of  the  conversion 
hysteria.  There  are  of  course  no  statistics  available  as  to 
the  number  of  purely  neurotic  heart  conditions  that  develop  at 
the  front.  It  is  safe  to  say,  however,  that  they  form  an  insig- 
nificant group  numerically  when  compared  to  the  anxiety 
states  and  common  conversion  hysterias.  The  reason  for  this 
is  probably  to  be  found  in  the  fact  that  there  is  nothing  that  is 
much  more  painful  both  mentally  and  physically  than  symp- 
toms of  heart  trouble  which  are  so  commonly  associated  with 
idea  of  death.  The  neurotic,  therefore,  who  is  unconsciously 
on  the  search  for  some  relief  is  much  more  apt  to  wish  for 
death  by  a  shell  or  a  bayonet  than  for  the  more  protracted 
and  painful  struggle  that  precedes  death  by  heart  failure- 


103 

General  Psychologicai,  Considerations. 

It  maybe  well  to  summarize  what  has  been  said  earlier  in 
this  report  by  a  few  generalizations  as  to  the  psychological 
mechanisms  at  work  in  the  production  of  the  war  neuroses. 
The  most  fundamental  factor  is  of  course  the  resistance  of 
the  officer  or  soldier  to  the  warfare  in  which  he  is  forced  to 
engage.  A  striking  feature  of  these  conditions  is  that  this 
resistance  can  be  present  in  the  patient's  mind  consciously 
and  still  operate  unconsciously  in  the  production  of  symp- 
toms, which  is  a  phenomenon  rarely  if  ever  met  with  in 
civilian  practice.  It  is  probably  more  accurate  to  say  that  the 
general  antagonism  to  the  situation  remains  conscious,  while 
some  specific  wish  for  relief  begins  to  operate  unconsciously 
and  reaches  expression  when  a  situation  develops  that 
facilitates  its  transformation  into  a  symptom. 

That  these  transformations  should  differ  so  widely  in  their 
nature  as  do  simple  hysterical  symptoms  and  the  mental 
torture  of  an  anxiety  state  demands  some  brief  discussion. 
The  first  clue  to  be  followed  in  solving  this  mystery  is  the 
striking  fact  that  the  vast  majority  of  those  suffering  from 
the  pure  anxiety  state  are  officers,  while  the  conversion  hys- 
terias are  almost  entirely  confined  to  the  privates  and  non- 
commissioned officers.  The  most  obvious  difference  between 
these  two  groups  of  men  lies  in  their  intelligence,  and  here 
we  find  an  analogy  with  the  experience  of  civilian  practice. 
The  common  conversion  hysterias  are  met  with  in  times  of 
peace  very  largely  among  the  lower  and  more  poorly  edu- 
cated classes,  while  more  intelligent  people  are  apt  to  be  free 
from  them.  One  explanation  of  this  may  be  that  the  mod- 
ern educated  man  knows  enough  of  neurology  to  realize, 
even  if  it  be  in  a  vague  way,  that  paralysis  comes  from 
injury  to  a  nerve  or  the  central  nervous  system  at  some 
distance  from  the  site  of  the  paralysis.  The  intelligent  lay- 
man, for  example,  knows  that  if  he  breaks  his  wrist  the 
forearm  and  hand  are  apt  to  be  painful  and  consequently 
there  may  be  some  weakness  in  the  forearm  and  hand,  but 
he  does  not  expect  that  all  the  muscles  involved  in  wrist 
movements  will  be  paralyzed.  He  would  expect  this 
to  occur  more  probably  after  a  paralytic  stroke,  injury  to 


104 

the  spinal  cord  or  an  accident  to  a  nerve  in  the  upper  arm. 
The  ignorant  dispensary  or  hospital  patient,  on  the  other 
hand,  has  a  definite  association  in  his  mind  between  local 
symptoms  and  local  functions  and  he  has  little  if  any  concep- 
tion of  nervous  control  from  a  distance.  An  example  of  this 
failure  to  localize  function  correctly  is  the  popular  use  of 
the  term  "  a  strong  wrist"  when  a  strong  forearm  is  really 
meant. 

But  the  difference  between  officers  and  men  does  not  be- 
gin and  end  with  intelligence  and  education.  That  one  is 
a  leader  and  another  a  follower  is  equally  the  result  of  a 
difference  in  ideals  and  emotional  attitude.  The  private's 
ambition  is  not  to  think  for  himself  but  to  follow  orders  im- 
plicitly and  to  sink  his  own  personality  so  far  as  that  may 
be  possible.  If  a  dangerous  project  is  on  foot  the  private 
is  not  in  a  situation  to  decide  whether  he  will  join  in  with  it 
or  use  some  caution — he  is  merely  faced  with  the  alterna- 
tives of  obeying  orders  or  being  court-martialed.  The 
officer  on  the  other  hand  has  to  a  larger  measure  the  respon- 
sibility of  individual  decision.  He  has  to  make  up  his  mind 
whether  he  is  or  is  not  going  to  give  a  certain  order — 
whether  he  will  or  will  not  expose  himself  to  danger.  More- 
over, it  is  his  duty  not  only  to  be  courageous  himself  and  to 
prevent  the  thoughts  of  his  personal  danger  from  disturbing 
his  judgment,  but  he  must  also  act  before  his  men  as  to  in- 
spire them  and  give  an  example  of  indifference  to  all  the 
hazards  of  war.  This  implies  that  the  officer  must  be  en- 
dowed with  higher  ideals  than  the  private  soldier.  It  is  to 
this  more  than  to  any  other  factor  probably  that  we  may  as- 
cribe the  difference  between  their  clinical  histories,  when 
war  neuroses  develop.  The  officer  who  feels  his  responsi- 
bility in  the  great  struggle  which  the  war  represents  is 
prepared  to  do  all  he  can  for  the  country,  even  to  the  point 
of  facing  death  itself,  but  before  that  final  release  may  come 
his  mind  stops  at  no  other  excuse.  When  fatigue  and  the 
horrors  of  war  grow  on  him,  therefore,  he  does  not  let  his 
fancy  play  with  any  failure  to  meet  his  full  responsibilities 
but  looks  forward  rather  to  making  the  supreme  sacrifice, 
namely,  that  of  dying  for  his  country.     The  private,  on  the 


105 

other  hand,  is  willing- to  accept  an  order  to  leave  the  trenches 
with  the  same  or  even  greater  willingness  than  he  will  obey 
an  order  to  advance  against  the  enemy.  The  most  obvious 
occasion  for  an  order  to  go  back  of  the  line  is,  of  course,  a 
wound  which  will  incapacitate  him  from  further  active  serv- 
ice audit  istherefore  "a  Blighty  one"  for  which  he  yearns. 
The  transformation  of  these  wishes  into  symptoms  is  the 
next  point  to  be  considered.  The  fate  of  the  private  is  a  sim- 
ple matter.  He  wishes  for  some  physical  disability  and 
when  the  appropriate  physical  or  mental  accident  occurs 
some  physical  disability  appears,  that  is  to  say,  a  conversion 
hysteria  develops  which  is,  so  far  as  he  can  see,  purely  a 
physical  disability,  and  his  mental  attitude  toward  the 
symptom  is  very  much  like  that  which  any  man  exhibits  to- 
ward a  wound  or  some  somatic  disease.  The  determination 
of  the  particular  symptom  can  usually  be  traced  to  some  pre- 
vious illness,  when  the  function  in  question  was  organically 
disturbed.  The  conversion  of  the  wish  for  death  into  the 
anxiety  symptom  is,  however,  not  so  obvious  a  matter.  In 
general  one  may  say  that  nightmares,  which  are  the  most 
distinctive  feature  of  the  anxiety  state,  do  not  seem  to  de- 
velop until  the  wish  for  death  has  appeared.  It  is  possible, 
therefore,  that  the  unconscious  mind  seizes  on  that  in  the 
environment  which  is  most  likely  to  occasion  death  and 
makes  the  patient  dream  of  this  danger.  The  "wish-ful- 
filment," therefore,  in  the  dream  of  being  shelled  or  bay- 
oneted may  be  ascribed  to  the  wish  for  death  which  may 
previously  have  been  rather  diffuse  and  now  becomes  speci- 
fically allied  with  one  particular  form  of  mortal  danger. 
To  account  for  the  presence  of  anxiety  in  these  dreams, 
when  there  has  been  previously  a  calm  desire  for  death,  is 
a  more  difl&cult  matter.  The  only  explanation  seems  to  be 
that  emotional  reactions  in  dreams  seem  to  represent  the 
natural  reactions  of  the  individual,  as  an  individual,  rather 
than  of  the  socialized  being  who  is  burdened  with  a  feeling 
of  moral  responsibility.  It  is  of  course  a  commonplace 
that  we  constantly  dream  of  performing  acts  which  we 
would  never  indulge  in  when  we  are  awake,  out  of  con- 
sideration for  the  feelings  of  others,  or  out  of  respect  for 


106 

laws  or  conventions.  In  a  somewhat  similar  way  our 
emotional  reaction  in  dreams  is  determined  bj''  our  more 
sel&sh  attitude  toward  the  situation  presented  in  the  dream. 
It  is  of  course  a  perfectly  normal  thing  for  any  man  to  be 
afraid  of  a  high  explosive  shell  or  of  a  baj^onet;  the 
instinct  of  self  preser\^ation  bids  him  be  afraid.  This  too 
is  his  initial  reaction  when  first  exposed  to  such  dangers, 
but  he  soon  learns  to  inhibit  this  fear  during  the  daj'time 
because  he  knows  that  it  is  his  dut}''  to  be  indifferent  to 
these  dangers.  This  inhibition  is  lifted  during  sleep, 
however,  and  consequently  his  emotional  reaction  during 
the  dream  is  that  which  anj^  civilian  would  have  when 
placed  in  such  an  extremity.  Another  factor  maN'  possi- 
bly also  enter  in.  Fear,  as  has  been  said,  is  a  protective 
reaction.  Now  the  individual  has  to  protect  himself 
from  real  dangers  not  onlj"  from  without  but  from  the  un- 
conscious cravings  which  are  at  variance  with  his  social 
standards.  All  the  protective  emotions  of  dreams  are  there- 
fore probabh"  operating  in  part  to  keep  the  unconscious 
tendencies  in  subjection — in  other  words,  to  keep  them  un- 
conscious. It  is  for  this  reason  that  any  man  is  often  most 
fearful  of  that  which  he  unconsciously  most  desires. 

The  unconscious  wish  for  death  b^^  some  definite  agency 
operates  in  many  cases  at  first  during  sleep  but  soon  it 
begins  to  show  itself  in  the  daytime.  Unconsciously  desir- 
ous of  being  hit  by  a  shell,  the  patient's  attention  is  more 
attracted  to  bombardment  than  it  previously  was,  conse- 
quently his  thoughts  become  focussed  willy  nilly  upon  it. 
It  is  then  that  the  instinctive  protective  reaction  of  fear 
develops,  perhaps  in  order  to  make  the  individual  shun  this 
danger.  The  patient  loses  the  ability  to  gauge  the  direction 
of  shells  b3^  their  sounds,  which  gives  a  beautiful  example 
of  how  the  unconscious  works  at  cross  purposes  from  the 
conscious  mind.  The  patient  has  consciously  no  fixed  and 
constant  desire  to  be  hit  by  a  shell.  Unconsciously  he  has, 
however;  so  in  the  fatigued  condition  from  which  he  suffers, 
the  unconscious  warps  his  judgment,  making  every  shell 
the  fulfilment  of  the  unconscious  wish. 

The  foregoing  speculations  as  to  the  psychological  stages 


107 

in  the  formation  of  anxiety  symptoms  refer  to  those  cases 
where  nightmares  precede  diurnal  fear.  This  does  not 
always  happen;  in  fact,  it  is  probably  of  rarer  occurrence 
than  the  reverse.  There  is  no  reason  to  suppose  that  there 
is  any  essential  difference  in  mechanism  between  the  two 
types  of  cases.  The  smaller  group  is  chosen  as  a  paradigm 
merely  because  unconscious  motivation  and  individualistic 
reactions  are  always  more  easily  observed  in  dreams  than  in 
the  reactions  of  walcing  life. 

It  is  now  more  or  less  of  an  axiom  that  unconscious  factors 
retain  their  power  very  largely  because  of  their  remaining 
unconscious,  and  so  beyond  the  sphere  of  influence  of  the 
individual's  judgment.  This  is  a  factor  of  no  small  impor- 
tance in  the  production  of  the  anxiety  states.  The  fear 
which  the  patient  feels  must  be  repressed.  He  is  ashamed 
of  showing  any  evidence  of  cowardice  before  either  his 
men  or  his  brother  officers.  He  is  therefore  the  subject  of  a 
conflict  which  he  must  fight  out  alone.  He  knows  that  he 
has  at  least  a  tendency  to  be  afraid,  but  he  also  knows  that 
he  can  maintain  the  respect  of  his  men  and  officer  friends 
so  long  as  he  keeps  that  fear  to  himself.  He  is  constantly 
repressing  this  most  natural  reaction  and  there  is  accumu- 
lated, naturally  enough,  a  stronger  and  stronger  tendency 
for  active  exhibitions  of  fear.  It  is  this  which  probably 
accounts  for  two  phenomena.  The  first  is  that  when  the 
patient  is  sent  back  from  the  trenches  to  the  hospital  and 
the  occasion  for  this  repression  removed  there  is  almost  in- 
variably a  sudden  increase  in  the  severity  of  the  symptoms. 
The  second  is  that  an  opportunity  for  the  frank  discussion 
of  a  man's  fear  with  his  physician  is  often  the  occasion  for 
his  "  getting  a  good  deal  oflF  his  chest  "  and  leads  to  marked 
improvement  in  his  condition. 

A  few  remarks  on  the  psychological  role  of  concussion 
may  not  be  out  of  place.  In  many  patients  in  whom  there 
have  been  gradually  accumulating  difficulties  not  sufficent  to 
incapacitate  the  patient  there  is  a  sudden  increase  of  symp- 
toms following  even  a  mild  concussion.  This  is  of  course 
quite  obviously  the  result  of  organic  injury  to  the  brain, 
but  how  this  affects  mental  mechanisms   should  be   con- 


108 

sidered.  As  has  just  been  said,  the  unconscious  seems  to 
be  a  prominent  factor  in  the  actual  production  of  symptoms. 
Normally,  the  unconscious  is  kept  under  such  severe 
repression  that  no  ideas  are  allowed  to  come  into  conscious- 
ness which  are  not  fully  adapted  to  the  situation  at  hand, 
so  that  the  reactions  of  the  individual  are  in  keeping^  with 
his  natural  standards  of  behavior.  This  repression,  how- 
ever, is  closely  related  to  the  higher  mental  functions,  and 
for  its  perfect  operation  demands  the  fullest  degree  of  both 
intellectual  and  moral  judgment.  Any  injury  to  the  brain 
naturally  affects  its  more  specialized  functions  first  and 
more  severely  than  it  does  those  functions  which  we  term 
"habitual"  or  instinctive.  Consequently  in  the  low  state 
of  mental  tension  consequent  on  cerebral  injury  the  higher 
functions  are  in  abeyance  and  the  unconscious  and  instinc- 
tive tendencies  can  readily  gain  the  upper  hand.  The 
situation  with  concussion  is  therefore — only  in  a  psycho- 
logical sense,  of  course — analogous  to  that  of  a  mental  shock. 
A  purely  psychic  trauma  so  confuses  the  patient's  ordinary 
mental  processes  that  his  critical  judgment  is  for  the  time 
being  impaired,  and  the  unconscious  has  an  opportunity  for 
fuller  expression  than  it  previously  enjoyed.  Both  concus- 
sion and  mental  shocks  are  by  their  nature  sudden.  We 
see  also  many  cases  in  which  there  is  a  gradual  increase  in 
the  severity  of  symptoms.  It  is  not  at  all  impossible  that 
modern  warfare  produces  conditions  of  such  extreme  neuro- 
psychic  fatigue  that  mental  tension  may  be  lowered  thereby 
to  that  same  level  of  inefficiency  that  occurs  acutely  with 
concussion  or  psychic  trauma.  The  process  is  necessarily 
more  gradual  with  the  unconscious  developing  symptoms 
in  inverse  proportion  to  the  weakening  strength  of  the 
critical  factors. 

Throughout  this  report  there  has  been  considerable  stress 
laid  on  the  psychological  aspects  of  the  war  neuroses.  In- 
asmuch as  it  seems  certain  that  purely  physical  factors  play 
a  larger  role  than  they  commonly  do  in  times  of  peace  in 
the  production  of  functional  nervous  disturbances,  this 
constant  emphasis  of  the  mental  aspects  of  the  neuroses 
demands  some  apology.  The  reason  for  it  is  a  purely  prac- 
tical one.     The  treatment  of  these  conditions,  in  so  far  as 


109 

it  demands  the  attention  of  specialists,  must  be  almost 
purely  psychological,  or,  to  put  the  matter  in  a  somewhat 
more  accurate  form,  it  may  be  said,  perhaps,  that  every 
method  of  treatment  instituted  must  be  carefully  considered 
in  the  light  of  its  probably  psychological  effect.  The 
physical  factors,  although  of  the  utmost  importance,  are 
beyond  our  present  capacity  to  change  specifically.  The 
best  we  can  do,  failing  knowledge  as  to  what  they  really 
are,  is  to  meet  them  symptomatically  with  such  simple 
measures  as  rest,  diet,  catharsis  or  sedation.  It  is  only  the 
physician  who  constantly  maintains  the  psychological 
standpoint,  however,  who  will  be  consistently  successful  in 
treating  the  war  neuroses. 

Prophylaxis. 

In  conclusion  it  may  be  well  to  speak  briefly  of  means 
that  may  be  taken  to  prevent  in  future  such  terrible  strains 
being  made  on  the  efficiency  of  fighting  forces  as  the 
neuroses  have  produced  in  all  the  armies  at  present  at 
war.  The  first  method  which  naturally  comes  to  mind  is 
the  removal  at  the  time  of  enlistment  of  all  men  who  are 
not  adapted  to  fighting.  This  is,  of  course,  a  simple 
recommendation  but  one  that  demands  keen  judgment  and 
wide  outlook  on  the  part  of  those  who  would  put  it  into 
operation.  One  difficulty  is  inseparable  from  the  problems 
of  war  itself.  It  must  be  obvious  to  every  reader  that  the 
vast  majority  of  cases  quoted  in  this  report  show  men  who 
are  well  adapted  to  civil  life  but  capable  only  to  a  limited 
degree  of  enduring  the  strain  of  modern  warfare.  The  sad 
fact  is  also  plain  that  the  very  qualities  which  may  be  the 
greatest  assets  to  the  civilian,  and  to  the  country  in  which 
he  lives,  may  be  just  those  characteristics  which  are  most 
apt  to  jeopardize  complete  adaptation  to  trench  warfare.  I 
need  only  mention  independence  of  judgment  and  a  strong 
feeling  of  sympathy  for  those  in  pain,  to  make  it  clear  that 
the  ideal  soldier  must  be  more  or  less  of  a  natural  butcher, 
a  man  who  can  easily  submit  to  the  domination  of  intel- 
lectual inferiors.  Whether  men  who  are  more  valuable  to 
the  State  as  civilians  than  they  are  as  soldiers,  should  be 
drafted  into  an  army  or  not,  is,  fortunately,  not  a  question 


110 

for  a  physician  examining  recruits  to  decide.  It  is  his 
duty,  rather,  to  make  up  his  mind,  after  an  examination  of 
any  given  applicant,  whether  the  chances  of  that  man's 
competency  in  the  firing  line  will  be  sufficiently  good  to 
justifj^  the  money  which  the  government  will  spend  in 
feeding,  clothing  and  training  him.  It  goes  without  saying 
that  all  men  should  be  eliminated  who  show  marked 
psychopathic  tendencies  or  who  are  obviously  psychoneu- 
rotic at  the  time  of  examination.  I  have  been  much 
impressed  with  the  large  number  of  cases  (many  of  which 
are  not  reported  here)  that  I  have  had  an  opportunity  of 
examining  who  gave  a  history  of  previous  breakdowns  or 
of  having  had  tendencies  toward  psychoneurotic  reactions  in 
their  past  life,  but  who  nevertheless  adapted  themselves  well 
to  training  and  fought  well  for  many  months,  some  of  them 
indefinitely.  I  am  therefore  forced  to  the  belief  that  there 
is  in  military  discipline  a  powerful  therapeutic  agency  and 
that  not  only  the  country  as  a  whole,  but  many  individuals, 
would  lose  a  great  deal  if  they  were  denied  service  in  the 
army  simply  because  they  could  show  a  history  of  some 
psychoneurotic  disturbances  in  the  past. 

The  problem  therefore  would  reduce  itself  to  a  matter  of 
gauging  the  probable  persistence  and  severity  of  such 
tendencies,  which  is  obviously  a  difficult  matter.  No  one 
of  course  who  is  ill-adapted  to  civilian  life  at  the  time  of 
enlistment  should  be  considered.  Those  patients  who  have 
given  a  history  of  such  tendencies  as  night  terrors,  fear  of 
the  dark,  fear  of  the  underground  or  fear  of  thunder-storms, 
and  who  present  no  evidence  of  having  outgrown  these 
tendencies,  who  are  still  in  considerable  measure  incapaci- 
tated by  them — all  such  persons  are  probably  poor  risks 
from  the  army  standpoint.  Again  it  is  practically  certain 
that  any  individual  who  is  in  times  of  peace  temporarily 
incapacitated  by  sights  of  cruelty,  bloodshed,  accidents, 
etc.,  is  very  unlikelj^  to  have  any  but  the  briefest  resistance 
to  the  constant  strain  imposed  by  the  inevitable  horrors  of 
war.  Such  symptoms  as  giddiness  in  high  places  are  so 
universal  as  to  have  practically  no  significance  when 
occurring  alone.  If  it  were  practicable  much  more  finality 
in  the  physician's  judgment  could  be  given  if  he  had  an 


lit 

opportunity  of  examining  recruits  twice.  In  his  first 
examination  he  could  pick  out  doubtful  cases  and  then 
reexamine  them  after  some  months  of  training  in  order  to 
discover  whether  the  military  life  had  had  a  salutary  or  a 
deteriorating  effect  on  them.  If  they  had  improved  they 
would  probably  be  good  risks.  If  they  had  not  improved, 
however,  it  would  be  highly  improbable  that  their  experience 
at  the  front  would  be  anything  but  temporary.  Although 
I  have  seen  many  cases  showing  neurotic  tendencies  who 
improved  under  training  and  became  excellent  soldiers,  I 
have  not  seen  one  who  failed  to  improve  under  training 
whose  condition  became  better  when  he  was  actually  in  the 
firing  line. 

The  next  problem  in  connection  with  prophylaxis  has  to 
do  with  lightening  so  far  as  possible  the  strain  that  is  inevi- 
table in  trench  warfare.  It  is  of  course  an  easy  matter  for 
the  physician  to  say  that  the  soldier  must  have  frequent 
relief  from  duty  and  be  given  all  possible  distractions,  and 
equally  easy  for  the  staff  oflScers  to  reply  that  such  coddling 
of  the  men  is  incompatible  with  the  conduct  of  a  campaign. 
Obviously  this  problem  is  at  once  both  a  military  and  a 
medical  one.  At  the  present  time  the  line  officers  of  the 
British  Army  are  as  acutely  aware  of  the  necessity  for  rest  and 
distraction  as  are  the  physicians,  and  the  reason  for  this  is 
that  they  have  discovered  that  no  matter  how  much  men 
may  be  forced  and  no  matter  how  willing  they  may  be  to 
continue  in  the  trenches  they  nevertheless  become  inefficient 
when  subjected  to  more  than  a  certain  amount  of  fatigue. 
If  at  all  feasible,  a  system  of  relief  should  be  worked  out  in 
conference  between  psychiatrists  and  the  staff.  If  also 
practicable,  a  certain  laxity  in  the  arrangements  should  be 
left  whereby  psychiatrists  might  be  allowed  the  privilege  of 
removing  certain  men  from  the  trenches  earlier  than  they 
would  their  fellows.  If  possible,  this  would  be  of  great 
military  advantage,  as  the  history  of  many  patients  show 
that  when  they  have  an  opportunity  to  rest  they  quickly 
recover  from  the  premonitory  symptoms  of  a  war  neurosis 
and  return  to  fight  again  quite  competently.  Once  the 
disease  has  progressed  beyond  a  certain  point,  however, 
there  seems  to  be  no  return  except  after  a  long  period  of 


112 

treatment.     The  best  criterion  I  have  been  able  to  discover 

for  permanence  of  symptoms  is  the  presence  of  repeated 
nightmares  of  actual  fighting.  I  was  not  able  to  find  a 
single  patient  who  had  once  shown  these  symptoms  and 
subsequently  improved  without  regular  and  protracted 
treatment.  These  remarks  refer  of  course  more  particularly 
to  the  anxiety  states  than  to  the  conversion  hysterias.  If 
all  the  private  soldiers  who  complain  of  the  milder  degree 
of  resistance  to  the  trenches,  which  so  many  of  these  men 
show  before  the  actual  hysteria  begins — if  all  these  men 
were  allowed  to  go  back  into  rest  camps  there  would  prob- 
ably be  very  little  army  left.  On  the  other  hand,  the 
officers  who  break  down  with  anxiety  conditions,  if  they 
are  good  officers  and  of  value  to  the  army,  are  men  who  would 
be  loth  to  leave  their  duty  unless  ordered  to  do  so.  It  goes 
without  saying  that  all  forms  of  comfort  and  distraction, 
particularly  the  presence  of  palatable  food  and  drink,  are  of 
importance  from  a  medical  standpoint  in  the  present  war  as 
they  never  have  been  before.  Where  every  factor  seems  to 
operate  in  making  it  hard  for  the  soldier  to  maintain  his 
adaptation — his  pleasure  in  the  service — it  is  essential  that 
his  difficulties  should  be  reduced  to  a  minimum,  and  that, 
on  the  other  hand,  he  should  be  furnished  with  every  pos- 
sible means  for  giving  him  that  pleasure  which  would 
distract  his  mind  from  all  that  is  unpleasant  and  horrible 
around  him. 

Finally,  when  men  are  sent  back  to  rest  camps  in  order 
to  recover  from  their  fatigue  it  would  be  highly  desirable 
that  they  should  receive  an  examination  before  they  return 
to  active  duty  again.  As  has  been  shown  in  a  number  of 
cases  in  this  report,  the  prospect  of  returning  to  duty,  when 
recovery  has  not  been  complete  is  frequently  the  occasion 
for  utter  discouragement  and  consequent  collapse.  In  a 
war  that  may  last  for  years  an  extra  week  or  even  an  extra 
month  of  absence  from  the  trenches  is  less  loss  to  the  army 
than  is  that  which  is  occasioned  by  the  protracted  conva- 
lescence which  follows  only  a  week,  perhaps,  of  efficient 
service.  Here  again  then  the  problem  is  reduced  to  a 
question  of  adapting  individual  treatment  to  the  military 
necessities  that  consider  all  men  alike. 


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